Prevention of Iatrogenic Anemia in Critical and Neonatal Care

Blood over-testing: impact, ethical issues and mitigating actions

Plenty of studies demonstrate that hospital-acquired anemia (HAA) can increase transfusion rates, mortality, morbidity and cause unnecessary patient burden, including additional length of hospital stay, sleep disruption and venipuncture harms resulting from blood samples unlikely to change clinical management. Beyond patient costs, community costs should also be considered, such as laboratory time and resources waste, environmental impact, increasing pressure on labs and fewer tests available on time for patients who can benefit from them most. Blood over-testing does not support the principles of non-maleficence, justice and respect for patient autonomy, at the expense dubious beneficence. Reducing the number and frequency of orders is possible, to a certain extent, by adopting nudge strategies and raising awareness among prescribing doctors. However, reducing the orders may appear unsafe to doctors and patients. Therefore, reducing blood volume from each order is a better alternative, which is worth implementing through technological, purchasing and organizational arrangements, possibly combined according to need (smaller tubes, adequate analytic platforms, blind dilution, blood conservative devices, aggregating tests and laboratory units).

Evaluation of the impact of diagnostic blood loss and red blood cell transfusion in very-low-birth-weight anaemic neonates during hospitalization: A multi-centre retrospective clinical study

BACKGROUND AND OBJECTIVES

Diagnostic blood loss is a significant factor in the development of anaemia in neonates with very low birth weight. This study aimed to assess the clinical efficacy of intervention approaches involving varying diagnostic blood loss and red blood cell transfusion volumes in neonates with very low birth weights experiencing anaemia during hospitalization.

MATERIALS AND METHODS

A total of 785 newborns with anaemia weighing less than 1500 g were enrolled from 32 hospitals in China. The study involved monitoring diagnostic blood loss and red blood cell transfusion and evaluating relevant interventions such as red blood cell transfusion and clinical outcomes. Three intervention approaches were established based on the difference between blood loss and transfusion (Intervention Approaches 0, 1 and 2). The primary outcomes measured were unsatisfactory weight gain during hospitalization and neonatal mortality. The secondary outcomes included related complications.

RESULTS

In the non-hospital-acquired anaemia group, Intervention Approach 2 had the highest incidence of below-normal weight gain (odds ratio [OR]: 3.019, 95% confidence interval [CI]: 1.081-8.431, p = 0.035). Multivariate analysis revealed that Intervention Approach 1 had a protective effect on weight gain. In the hospital-acquired anaemia group, Intervention Approach 2 had the highest incidence of below-normal weight gain (OR: 3.335, 95% CI: 1.785-6.234, p = 0.000) and mortality (OR: 5.341, 95% CI: 2.449-11.645, p = 0.000), while Intervention Approach 1 had the lowest incidence of intraventricular haemorrhage. Intervention Approach 1 demonstrated favourable outcomes in both anaemia groups.

CONCLUSION

Intervention Approach 1 improved weight gain and reduced mortality and complications in both the non-hospital-acquired and hospital-acquired anaemia groups.

Use of urine neutrophil gelatinase-associated lipocalin for nephrotoxic medication acute kidney injury screening in neonates

BACKGROUND

Daily serum creatinine monitoring protocols for acute kidney injury (AKI) are invasive and may lead to surveillance resistance. We aimed to understand if use of urine neutrophil gelatinase-associated lipocalin (uNGAL) could increase high-risk nephrotoxic medication (NTMx) associated AKI screening adherence in neonates.

METHODS

Statistical process control methods prior to and post implementation were trended. The primary outcome, screening adherence, was defined as either daily serum creatinine or uNGAL assessment through 2 days post high-risk NTMx exposure.

RESULTS

1291 monitoring days from the pre-implementation era (4/2020-6/2021) were compared to1377 monitoring days from the post-era (6/2021-10/2022). AKI screening adherence increased (81 to 92%) following implementation of optional uNGAL screening. Urine NGAL accounted for 35% of screening obtained. Use of uNGAL resulted in a 40% reduction in blood sampling for serum creatinine.

CONCLUSIONS

Incorporation of uNGAL as a complementary screening tool to serum creatinine demonstrated sustained increased AKI surveillance in our Baby NINJA monitoring program.

Optimizing haemoglobin measurements in VLBW newborns: Insights from a comparative retrospective study

INTRODUCTION

Haemoglobin levels assessment is a crucial part of neonatal intensive care practice, the painful experience of repeated heel pricks and venepunctures blood sampling may negatively affect neonatal clinical course. To date the reliability of haemoglobin levels obtained by point-of-care testing (POCT) analysis if compared to standard blood cell count remains controversial.

MATERIALS AND METHODS

Retrospective study conducted on all inborn premature infants (gestational age < 32 weeks) admitted to NICU of the IRCCS Giannina Gaslini Institute during the period May 2021-April 2023. We considered blood samplings occurred within the first 28 days of life recording the laboratory haemoglobin levels (Hblab) (reference method), the point-of-care haemoglobin levels (HbPOCT) (alternative method) and the type of puncture (arterial, venous and capillary). A Bland-Altman analysis was performed to evaluate the Hb agreement, it determines the bias (mean difference between the reference and alternative methods) and limits of agreement (LOA; lower, l-LOA; upper, u-LOA) of measures. An acceptable limit of agreement was 1 g/dl according to the existing literature.

RESULTS

We considered 845 blood samplings from 189 enrolled patients. The comparison between the reference and the alternative method showed a good agreement for the capillary sampling technique with l-LOA of -0.717 (-0.776; -0.659) and u-LOA of 0.549 (0.490; 0.607), these results were not achievable with the other techniques, with LOAs over ±1 g/dl threshold (venous

CONCLUSIONS

The reliability of capillary POCT measured haemoglobin levels may reduce clinical-related costs and the number of painful experiences, with obvious positive effects on the daily neonatal life in the NICU and on the developing brain structures.

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Key Words

• Capillary sampling
• Haemoglobin
• Neurodevelopment
• Newborn
• POCT
• Procedural pain

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MESH Headings

• Infant
• Humans
• Infant, Newborn
• Retrospective Studies
• Reproducibility of Results
• Hemoglobins/analysis
• Point-of-Care Testing
• Infant, Premature

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Affiliation(s)

Andrea Calandrino Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Carolina Montobbio Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy.
Irene Bonato Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Gaia Cipresso Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Francesco Vinci Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Samuele Caruggi Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Marcella Battaglini Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Chiara Andreato Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Federica Mongelli Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Paolo Massirio Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Giorgia Brigati Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Diego Minghetti Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy
Luca Antonio Ramenghi Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, 16132 Genoa, Italy; Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, 16147 Genoa, Italy

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Effect of using smaller blood volume tubes and closed blood collection devices on total blood loss in patients undergoing major cardiac and vascular surgery

BACKGROUND

Diagnostic laboratory tests are an integral part of managing hospitalized patients. In particular, patients in the intensive care units (ICUs) can experience a concerning amount of blood loss due to diagnostic testing, which can increase the risk developing iatrogenic anemia. Several interventions exist to curtail avoidable blood loss, for example computerized decision support, smaller phlebotomy tubes, and other blood conservation devices. Nevertheless, use of these interventions is not standardized. Therefore, the objective of our study was to quantify the daily phlebotomy volume taken from patients who had undergone major cardiac or vascular surgery.

METHODS

We estimated the number of blood analyses and volumes of drawn blood of 400 consecutive patients (≥ 18 yr) undergoing major cardiac or vascular surgery. The amount of blood saved using small-volume tubes and in combination with blood conservation device rather than standard-volume tubes was estimated for serum chemistry (serum), ethylenediaminetetraacetic acid (EDTA) tubes, sodium citrate coagulation (SCC) tubes, and arterial blood gas (ABG) analysis.

RESULTS

The mean total blood loss due to phlebotomy drawing using standard-volume tubes during hospitalization was 167.9 mL (95% confidence interval [CI], 158.0 to 177.8), 255.6 mL (95% CI, 226.5 to 284.6), and 695.3 mL (95% CI, 544.1 to 846.4) for patients undergoing cardiac surgery with a hospital length of stay (LOS) of 0-10, 11-20, and ≥ 21 days, respectively. The mean total blood loss due to phlebotomy during hospitalization was 80.5 mL (95% CI, 70.5 to 90.6), 225.0 mL (95% CI, 135.1 to 314.8 mL) and 470.3 mL (95% CI, 333.5 to 607.1) for vascular surgery patients with LOS 0-10, 11-20, and ≥ 21 days, respectively. Patients with at least a two-day stay at the ICU had a mean blood loss of 146.6 mL (95% CI, 134.6 to 158.6 mL) and those with ≥ 11 days incurred a loss of 1,428 mL (95% CI, 1,117.8 to 1,739.2). The use of closed blood collection device and small-volume tubes (serum, EDTA, SCC, and ABG) reduced blood loss by 82.8 mL for patients with an ICU stay of 2 days and up to 824.0 mL for patients with a ICU stay of ≥ 11 days.

CONCLUSION

Diagnostic laboratory tests are associated with significant patient blood loss, but are a modifiable risk factor. The use of small-volume tubes and closed blood collection devices decreases the volume of patient blood drawn for analysis and prevents blood waste.

Risk Factors Analysis for Hemoglobin Decline Caused by Diagnostic Blood Collection in Respiratory Department in North China: A Case-Control Study

Purpose

This study aimed to investigate the correlation between hemoglobin decline and diagnostic blood collection in the respiratory department and analyze the decline's risk factors.

Patients and Methods

A case-control study in the respiratory department of a national tertiary hospital in north China, multivariable logistic regression analysis was used to find the risk factors. Patients excluding other factors affecting hemoglobin other than blood collection in the year 2021 were enrolled and divided into two groups according to the D-value of hemoglobin. The degree of hemoglobin decline caused by diagnostic blood collection between discharge and admission and its risk factors were analyzed.

Results

Among the 530 patients screened in the study, ΔHb (the D-value of hemoglobin between discharge and admission) showed a skewed distribution with an average value of -4.38±0.514 g/L. We defined the D-value less than mean-2SD (ΔHb<-5.408) as a significant hemoglobin decline, by which the patients were categorized into two groups. Some variables had apparent differences between the two groups. By multivariable logistic regression analysis on these variables, the independent risk factors for significant hemoglobin decline (ΔHb<-5.408g/L) were revealed: age (OR=1.020, 95% CI 1.008-1.032, p=0.001), Male gender (OR=1.544, 95% CI 1.011-2.358, p=0.044), hemoglobin value at admission (OR=1.052, 95% CI 1.039-1.065, p<0.001), total blood collection volume (OR=1.021, 95% CI 1.010-1.032, p<0.001).

Conclusion

In the respiratory department, older male and more diagnostic blood collection mean higher risks of significant hemoglobin decline. Surprisingly, the lower the hemoglobin value at admission, the lower the risk.

Patient blood management in critically ill children undergoing cardiac surgery: A cohort study

OBJECTIVE

The objective of this study was to audit current patient blood management practice in children throughout cardiac surgery and paediatric intensive care unit (PICU) admission.

DESIGN

This was a prospective observational cohort study.

SETTING

This was a single-centre study in the cardiac operating room (OR) and PICU in a major tertiary children's hospital in Australia.

PATIENTS

Children undergoing corrective cardiac surgery and requiring admission to PICU for postoperative recovery were included in the study.

MEASUREMENTS AND MAIN RESULTS

Fifty-six patients and 1779 blood sampling episodes were audited over a 7-month period. The median age was 9 months (interquartile range [IQR] = 1-102), with the majority (n = 30 [54%]) younger than 12 months. The median number of blood sampling episodes per patient per day was 6.6 (IQR = 5.8-8.0) in total, with a median of 5.0 (IQR = 4.0-7.5) episodes in the OR and 5.0 (IQR = 3.4-6.2) episodes per day throughout PICU admission. The most common reason for blood tests across both OR and PICU settings was arterial blood gas analysis (total median = 86%, IQR = 79-96). The overall median blood sampling volume per kg of bodyweight, patient, and day was 0.63 mL (IQR = 0.20-1.14) in total. Median blood loss for each patient was 3.5 mL/kg per patient per day (IQR = 1.7-5.6) with negligible amounts in the OR and a median of 3.6 mL/kg (IQR = 1.7-5.7) in the PICU. The median Cell Saver® transfusion volume was 9.9 mL/kg per patient per day (IQR = 4.0-19.1) in the OR. The overall median volume of other infusion products (albumin 4%, albumin 20%, packed red blood cells) received by each patient was 20.1 mL/kg (IQR = 10.7-36.4) per day. Sampling events and blood loss were positively associated with PICU stay.

CONCLUSIONS

Patient blood management practices observed in this study largely conform to National Blood Authority guidelines. Further implementation projects and research are needed to accelerate implementation of known effective blood conservation strategies within paediatric critical care environments.

Hematological changes in neonatal mice with phlebotomy-induced anemia

BACKGROUND

Anemia is a nearly universal diagnosis in preterm infants, caused by phlebotomy, and exacerbated by the underlying erythropoietic immaturity. Newborn infants are exposed to the unique stressor of fetal-to-neonatal transition, which requires significant adaptation ex utero. Accordingly, the preterm infant's response to anemia may alter the ability to confront underlying illness. This study utilized our preclinical mouse model of phlebotomy-induced anemia (PIA) to comprehensively investigate associated hematological changes.

METHODS

C57BL/6 mice were subjected to timed phlebotomy between postnatal days 2--10 to induce severe anemia. Complete blood counts were determined by the Sysmex XT-2000iV analyzer.

RESULTS

Anemic pups showed a gradual reduction of RBC and hemoglobin (Hb) and increased reticulocyte (RET) counts and red cell distribution width (RDW), however, with reduced RET-Hb from postnatal day (P) of 4 onwards. Elevated levels of high fluorescent RET and immature reticulocyte fraction (IRF) were noted in anemic mouse pups, but low and medium fluorescent RET were reduced. Also, the reduction of mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were noted in anemic pups. No changes were seen in lymphocytes, but monocytes and neutrophils were significantly elevated from P4-P6.

CONCLUSIONS

PIA in mouse pups is associated with hematological changes that may be exacerbating factors in neonatal diseases.

IMPACT

Anemia is common and often severe in premature infants. Investigation of hematological parameters in settings of preclinical anemia may be an index of therapeutic strategies. Preclinical model evaluating the effects of neonatal anemia on the remainder of complete blood count. Detailed time kinetic phlebotomy-induced anemic mice enable us to study the impact on developmental delays in erythropoiesis and possible strategic intervention. Hematological effects of severe anemia in mice might provide insight on how best to investigate anemia in preterm infants.

Gas in scattering media absorption spectroscopy as a potential tool in neonatal respiratory care

Gas in scattering media absorption spectroscopy (GASMAS) is a novel optical technology employing near-infrared light. It has a potential use in the medical setting as a monitoring and diagnostic tool by detecting molecular oxygen within gas pockets and thus may be a useful adjunct in respiratory monitoring. GASMAS has potential advantages over other monitoring devices currently used in clinical practice. It is a non-invasive, continuous, non-ionising technology and provides unique information about molecular oxygen content inside the lungs. GASMAS may have a future role in optimising respiratory management of neonates in different clinical scenarios such as monitoring cardiorespiratory transition in the delivery room, assessing surfactant deficiency, and optimising endotracheal tube positioning. This article aims to summarise current evidence exploring GASMAS application in a neonate, discuss possible clinical benefits, and compare with other devices that are currently used in neonatal care. IMPACT: This article presents a novel optical technique to measure lung oxygen concentrations that may have important clinical uses. This review summarises the current literature investigating the concept of optical lung oxygen measurement. Information from this review can guide researchers in future studies.

Dynamic Monitoring of Systemic Biomarkers with Gastric Sensors

Continuous monitoring in the intensive care setting has transformed the capacity to rapidly respond with interventions for patients in extremis. Noninvasive monitoring has generally been limited to transdermal or intravascular systems coupled to transducers including oxygen saturation or pressure. Here it is hypothesized that gastric fluid (GF) and gases, accessible through nasogastric (NG) tubes, commonly found in intensive care settings, can provide continuous access to a broad range of biomarkers. A broad characterization of biomarkers in swine GF coupled to time-matched serum is conducted . The relationship and kinetics of GF-derived analyte level dynamics is established by correlating these to serum levels in an acute renal failure and an inducible stress model performed in swine. The ability to monitor ketone levels and an inhaled anaesthetic agent (isoflurane) in vivo is demonstrated with novel NG-compatible sensor systems in swine. Gastric access remains a main stay in the care of the critically ill patient, and here the potential is established to harness this establishes route for analyte evaluation for clinical management.

Carbon dioxide monitoring in the newborn infant

Carbon dioxide (CO₂ ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO₂ levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO₂ (EtCO₂ ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO₂ measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO₂ can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.

Iatrogenic Blood Loss in Very Low Birth Weight Infants and Transfusion of Packed Red Blood Cells in a Tertiary Care Neonatal Intensive Care Unit

An adequate blood volume is important for neonatal adaptation. The study objective was to quantify the cumulative iatrogenic blood loss in very low birth weight (VLBW) infants by blood sampling and the necessity of packed red cell transfusions from birth to discharge from the hospital. In total, 132 consecutive VLBW infants were treated in 2019 and 2020 with a median birth weight of 1180 g (range 370–1495 g) and a median length of stay of 54 days (range 0–154 days) were included. During the initial four weeks of life, the median absolute amount of blood sampling was 16.5 mL (IQR 12.3–21.1 mL), sampling volume was different with 14.0 mL (IQR 12.1–16.2 mL) for non-transfused infants and 21.6 mL (IQR 17.5–29.4 mL) for transfused infants. During the entire length of stay, 31.8% of the patients had at least one transfusion. In a generalized logistic regression model, the cumulative amount of blood sampling (p < 0.01) and lower hematocrit at birth (p = 0.02) were independent predictors for the necessity of blood transfusion. Therefore, optimized patient blood management in VLBW neonates should include sparse blood sampling to avoid iatrogenic blood loss.

Reducing neonatal phlebotomy blood losses through the accurate calculation of minimum test volume requirements

BACKGROUND

Repeated phlebotomy for laboratory diagnostic testing is a known cause of iatrogenic anaemia and in critically ill neonates often leads to blood transfusion being required. This study has developed a spreadsheet clinical decision support tool to allow neonatal staff to determine the true minimum blood volume required to analyse groups of blood tests and modelled its potential benefit compared with the existing system in use.

METHODS

The tool calculates the minimum blood volume accounting for novel factors including the current patient haematocrit for plasma/serum samples, instrument minimum test and dead volumes (including those where shared) and sharing of samples within/between laboratory departments. A year of neonatal unit laboratory requests were examined comparing the volumes and containers of blood recommended by the hospital information system with both the amount actually collected by staff and that recommended by the tool.

RESULTS

A total of 463 patients had 8481 blood draws for 23,899 tests or test profiles over the year. The hospital information system recommended collecting 11,222 mL of blood into 18,509 containers, while 17,734 containers were actually received (10,717 mL if fully filled). The tool recommended collecting 4915 mL of blood into 15,549 containers.

CONCLUSIONS

This tool allows neonatal intensive care unit staff to objectively determine the minimum blood volume required for a combination of tests and is generalizable between laboratory instruments. Compared with the hospital information system, use of the minimum blood volume clinical decision support tool could maximally reduce the volume of blood collected from this neonatal unit by more than a half. Neonatal intensive care unit staff had apparently already gone some way to determining their own minimum volumes required.

The Comparison of Hemoglobin Values Measured by Blood and Continuous Non-Invasive Monitoring (SpHb) in Newborn Infants

OBJECTIVE

Hemoglobin (Hb) measurement is one of the most commonly used laboratory tests in medical practice. Unnecessary blood sampling, especially in neonatal intensive care units (NICUs), contributes to iatrogenic anemia. Continuous non-invasive monitoring of total Hb (SpHb) was compared with invasive venous blood samples (tHb) in NICU patients.

METHODS

Three hundred and ten patients were identified in NICU. Non-invasive Hb measurement was performed immediately before venous blood sampling and comparison of invasive with non-invasive values was undertaken.

RESULTS

There was a strongly positive correlation between SpHb and tHb (r = 0.965, p < 0.001). Bland-Altman analysis was performed in 95% limits of agreement for Hb values measured by both methods. The mean bias between tHb and SpHb measurements was 0.05 g/dl (-1.85 to 1.96). In Passing-Bablok regression analysis, the CUSUM test p value was found to be 0.98 for Hb levels measured by SpHb and tHb; and the difference between the methods was not significant.

CONCLUSION

In newborns, SpHb method offers reliable Hb values, which are comparable with the more traditional tHb method. Continuous non-invasive monitoring of total Hb may help prevent unnecessary blood sampling and iatrogenic anemia. Further clinical studies are required for the effectiveness of the method in critically ill patients with circulatory disorders.

End-tidal capnography monitoring in infants ventilated on the neonatal intensive care unit

OBJECTIVE

To assess whether end-tidal capnography (EtCO2) monitoring reduced the magnitude of difference in carbon dioxide (CO2) levels and the number of blood gases in ventilated infants.

STUDY DESIGN

A case-control study of a prospective cohort (n = 36) with capnography monitoring and matched historical controls (n = 36).

RESULT

The infants had a median gestational age of 31.6 weeks. A reduction in the highest CO2 level on day 1 after birth was observed after the introduction of EtCO2 monitoring (p = 0.043). There was also a reduction in the magnitude of difference in CO2 levels on days 1 (p = 0.002) and 4 (p = 0.049) after birth. There was no significant difference in the number of blood gases.

CONCLUSION

Continuous end-tidal capnography monitoring in ventilated infants was associated with a reduction in the degree of the magnitude of difference in CO2 levels and highest level of CO2 on the first day after birth.

Use of platelet components: An observational audit at a tertiary care centre

Background Platelets should be transfused appropriately, based on the cause of thrombocytopenia. The practice and policies of transfusion vary among institutions and even among clinical practitioners, leading to inappropriate use of platelets, which might increase the risk of transfusion-related complications to recipients, and lead to a shortage of platelets. An audit of platelet components helps to determine the effectiveness and appropriateness of their use and in improving transfusion practices. We did an audit of the use of platelet transfusions at our centre. Methods We conducted a prospective concurrent audit of the platelet transfusion practices. The audit cycle had four steps: (i) defining the standards; (ii) data collection; (iii) comparison against the standards; and (iv) presenting them to clinicians for further improvement. Results Platelet components were used appropriately in 93.6% (2420/2586) of episodes. The platelet count was not done before transfusion in only 6.4% (165/2586) of episodes. The dose of platelets was given appropriately in 84.3% (2180) of episodes of transfusion. Indications for appropriate transfusion classified as pre-procedure, prophylactic and therapeutic transfusions were 11.3% (293), 66.1% (1450) and 13% (412), respectively. Medicine and medical oncology were the specialties with the highest level of appropriateness. Conclusion An audit of transfusion practices benefits transfusion services and clinicians in terms of judicious use of platelet components and better inventory management.

Performance evaluation of the Roche cobas 6800 system for quantifying cytomegalovirus DNA in plasma and urine samples

INTRODUCTION

Cytomegalovirus (CMV) nucleic acid amplification testing is important for CMV infection diagnosis and management. CMV DNA is found in plasma and various other fluids, including urine. If CMV can be reliably detected in urine, it may be considered a non-invasive alternative to blood tests. The cobas 6800 system (Roche Diagnostics, Mannheim, Germany) is a Food and Drug Administration-approved testing platform for measuring CMV DNA in plasma.

OBJECTIVE

To evaluate the analytical performance of the cobas 6800 system and compare the clinical feasibility of CMV detection in plasma and urine samples.

STUDY DESIGN

Imprecision, linearity, limit of quantitation (LOQ), and cross-reactivity of the cobas 6800 system were assessed, and reference interval verification was performed. Plasma CMV DNA quantification was compared to CMV DNA values in urine samples obtained from 129 pediatric patients (<18 years of age) from March 2020 to May 2020 at a tertiary hospital.

RESULTS

The assay precision was within the acceptable range. Linearity was observed within the tested concentration range (2.36-6.33 log IU/mL) with a coefficient of determination of 0.9972. The LOQ was 34.5 IU/mL. The assay did not show cross-reactivity with 15 other viruses. Plasma and urine detection results were stratified into three categories: negative, <LOQ, and positive to analyze the degree of agreement with the results. The quadratic weighted kappa value was 0.623 (P = 0.000), showing substantial concurrence.

CONCLUSION

The cobas 6800 system offers good sensitivity, precision, and linearity and is suitable for monitoring CMV viral loads in the plasma and urine samples.

Suitability of Placental Blood Samples of Newborns for Pre-Transfusion Testing

Objective: To show concordance between heel stick and placental blood sample pairs for newborns' pre-transfusion testing and to validate placental blood's tube and gel methodology. Methods: Placental samples were collected for pre-transfusion testing at birth from 78 singleton and twin newborns admitted to our Mother-Baby Unit to compare with the results of heel stick samples taken from same newborns. Gestational age ≥35 weeks, weight ≥2,000 g. The study was approved by the Institutional Review Board (IRB). Informed consent was obtained from newborn parents. ABO blood group, Rhesus factor (Rh), direct antiglobulin test (DAT), and antibody screen were performed. Ortho ProVue Analyzer was used for tube and gel methods. McNemar's test for paired categorical data was performed. Results: One hundred percent concordance in 78 pairs for ABO and Rh. Seventy-four pairs were tested for antibodies, 72 were both negative, 1 was both positive, and 1 gave discordant result. Ninety-nine percent concordance, p = 0.999. Sixty-five pairs were both DAT negative, seven were both DAT positive, and six gave discordant results. Ninety-two percent concordance, p = 0.68. Placental blood gave identical results comparing tube with gel methods. Conclusions: Placental blood is suitable for pre-transfusion testing and can replace heel sticks. Placental blood tube and gel methods are validated.

Changes in the Use of Fresh-Frozen Plasma Transfusions in Preterm Neonates: A Single Center Experience

The aim of this study was to evaluate changes in the use of fresh-frozen plasma (FFP) transfusions and the use of clotting tests in preterm neonates in our center over the past two decades. In this retrospective cohort analysis, we included all consecutive neonates with a gestational age at birth between 24 + 0 and 31 + 6 weeks admitted to our neonatal intensive care unit (NICU) between 2004 and 2019. We divided all included neonates into three consecutive time epochs according to date of birth: January 2004 to April 2009, May 2009 to August 2014 and September 2014 to December 2019. The main outcomes were the use of FFP transfusion, coagulation testing and the indications for FFP transfusion. The percentage of preterm neonates receiving FFP transfusion decreased from 5.7% (47/824) to 3.7% (30/901) to 2.0% (17/852) from the first epoch to the last epoch (p < 0.001). Additionally, the rate of neonates undergoing coagulation testing decreased from 24.3% (200/824) to 14.5% (131/901) to 8% (68/852) over the epochs (p < 0.001). Most FFP transfusions were prescribed prophylactically based on prolongation of activated partial thromboplastin time (aPTT) or prothrombin time (PT) (56%). In conclusion, both the use of FFP transfusions and the use of coagulation tests decreased significantly over the years. The majority of the FFP transfusions were administrated prophylactically for abnormal coagulation tests.

[Laboratory testing in intensive care medicine]

Despite the tremendous technological developments in medicine, careful history-taking and clinical examination remain the cornerstones of diagnostics. Numerous laboratory tests are ordered in intensive care and emergency medicine. The rate of overutilization of these tests during initial patient admission is almost 50%. Patient history may be frequently insufficient for conducting targeted laboratory testing, and concern about not overlooking a pathology also contributes to laboratory test overutilization. On the other hand, laboratory test profiles are frequently defined a priori to simplify the management process. However, these profiles are commonly based on symptoms rather than on a suspected diagnosis. Several laboratory variables are outside the normal range in critically ill patients. However, normal ranges are defined on the basis of data from healthy subjects, and these do not allow for a clear distinction between stress adaptation and clinically relevant changes that require correction. Pathophysiological changes due to the acute injury in critically ill patients and the reaction of the organism to the injury or even to the treatment itself can lead to changes in laboratory values. Untargeted laboratory tests contribute to iatrogenic anemia and increased costs. The results of such tests are either hardly noticed or, in the worst case, lead to further unnecessary diagnostic steps and unjustified therapeutic measures. Point-of-care laboratory tests, including blood gas analysis, blood count, serum electrolytes, and lactate, to assess the patient's homeostatic state and laboratory data for the relevant critical care scores are uniformly required. Beyond that, every laboratory test should be chosen wisely based on a concrete clinical question.

Reference Laboratory Testing for Neurologic Disorders

Laboratory testing plays a critical role in the diagnosis and monitoring of patients with neurologic disorders. Although common tests are often performed in a central hospital laboratory, an increasing number of essential but esoteric tests are performed at reference laboratories or other outside health care facilities. In this article, we analyze recent trends in neurologic disease testing within the overall context of reference laboratory testing and discuss strategies to facilitate the provision of high-quality, cost-effective laboratory services.

Blood culture sampling rate in hospitalised children as a quality indicator for diagnostic stewardship

PURPOSE

Recommendations regarding the optimal number of blood cultures in children are not available. The aim of this article is to describe the correlation between blood culture (BC) rates and laboratory-confirmed bloodstream infection (LCBSI) rates, on different paediatric wards of a tertiary-care centre in Germany.

METHODS

We conducted a retrospective cohort study in a paediatric university hospital, from 1st January to 31st December 2018. All blood cultures collected from neonatal (NICU) and paediatric intensive-care units (PICU), haematology/oncology, and general paediatric wards were included. There were no exclusion criteria. BC taken/1000 patients-days (BC rates/BCR) and LCBSI/1000 patient-days at risk (LCBSI rates) were calculated for each unit.

RESULTS

A total of 6040 patients were admitted to the hospital with 3114 of them into wards studied. Of the 3072 BCs collected, 200 (6.5%) were positive. Collection of BCs was performed in 51/77 (66.2%) of admitted patients on NICU, in 151/399 (37.8%) of PICU patients, in 163/755 (21.6%) of haematology/oncology patients, and in 281/1883 (14.9%) of children on general paediatric wards. Gram-positive bacteria were the most commonly detected organisms in blood cultures from all wards with exception of NICU. The BCR in NICU, PICU, haematology/oncology wards, and general wards were 61.6, 196.2, 358.4, and 52.3, respectively. Excluding commensal pathogens and possible contaminations, the LCBSI rates in the same units were 2.4, 5.6, 4.4, and 1.0, respectively.

CONCLUSION

We found different BCR values according the ward studied, being higher in patients with high risk of bloodstream infection such as haematology/oncology patients.

A Narrative Review on Hospital-Acquired Anemia: Keeping Blood where It Belongs

Hospital-acquired anemia (HAA) is a prevalent condition that is independently associated with worse clinical outcomes including prolongation of hospital stay and increased morbidity and mortality. While multifactorial in general, iatrogenic blood loss has been long recognized as one of the key contributing factors to development and worsening of HAA during hospital stay. Patients can be losing over 50 mL of blood per day to diagnostic blood draws. Strategies such as elimination of unnecessary laboratory tests that are not likely to alter the course of management, use of pediatric-size or small-volume tubes for blood collection to reduce phlebotomy volumes and avoid blood wastage, use of closed blood sampling devices, and substituting invasive tests with point-of-care testing alone or bundled together have generally been shown to be effective in reducing the volume of iatrogenic blood loss, hemoglobin decline, and blood transfusions, with no negative impact on the availability of test results for the clinical team. These strategies are important components of Patient Blood Management programs and their adoption can lead to improved clinical outcomes for patients.

Vecuronium- and Esmolol-Induced Pseudohypernatremia Due to Drug Interference With Ion-Selective Electrodes

Objectives

We observed that patients treated with continuous vecuronium or esmolol infusions showed elevated plasma sodium measurements when measured by the routine chemistry analyzer as part of the basic metabolic panel (Vitros 5600; Ortho Clinical Diagnostics, Raritan, NJ), but not by blood gas analyzers (RAPIDLab 1265; Siemens, Tarrytown, NY). Both instruments use direct ion-selective electrode technology, albeit with different sodium ionophores (basic metabolic panel: methyl monensin, blood gas: glass). We questioned if the basic metabolic panel hypernatremia represents artefactual pseudohypernatremia.

Design

We added vecuronium bromide or esmolol hydrochloric acid to pooled plasma samples and compared sodium values measured by both methodologies. We queried sodium results from the electronic medical records of patients admitted at Children's Hospital of Philadelphia from 2016 to 2018 and received vecuronium and/or esmolol infusion treatment during their admissions.

Setting

PICU of a quaternary, free-standing children's hospital.

Patients

Children admitted to the hospital who received vecuronium and/or esmolol infusion.

Measurements and Main Results

Sodium was measured in pooled plasma samples by basic metabolic panel and blood gas methodologies after adding vecuronium bromide or esmolol hydrochloric acid, leading to a dose-response increase in basic metabolic panel sodium measurements. A repeated measures regression analysis of our electronic medical records showed that the vecuronium dose predicted the Δ sodium (basic metabolic panel-blood gas) sodium within 12 hours of the vecuronium administration (p < 0.0018). Esmolol showed a similar trend (p = 0.13). This occurred primarily in central line samples with continuous vecuronium or esmolol infusions.

Conclusions

Vecuronium and esmolol can falsely elevate direct ion-selective electrode sodium measurements on Vitros chemistry analyzers. Unexpectedly high sodium measurements in patients receiving vecuronium and/or esmolol infusions should be further investigated with an alternate sample type (i.e., peripheral blood) or measurement methodology (i.e., blood gas) to guide treatment decisions.

Digital Microfluidic Platform to Maximize Diagnostic Tests with Low Sample Volumes from Newborns and Pediatric Patients

"Children are not tiny adults" is an adage commonly used in pediatrics to emphasize the fact that children often have different physiological responses to sickness and trauma compared to adults. However, despite widespread acceptance of this concept, diagnostic blood testing is an excellent example of clinical care that is not yet customized to the needs of children, especially newborns. Cumulative blood loss resulting from clinical testing does not typically impact critically ill adult patients, but can quickly escalate in children, leading to iatrogenic anemia and related comorbidities. Moreover, the tests prioritized for rapid, near-patient testing in adults are not always the most clinically relevant tests for children or newborns. This report describes the development of a digital microfluidic testing platform and associated clinical assays purposely curated to address current shortcomings in pediatric laboratory testing by using microliter volumes (<50 µL) of samples. The automated platform consists of a small instrument and single-use cartridges, which contain all reagents necessary to prepare the sample and perform the assay. Electrowetting technology is used to precisely manipulate nanoliter-sized droplets of samples and reagents inside the cartridge. To date, we have automated three disparate types of assays (biochemical assays, immunoassays, and molecular assays) on the platform and have developed over two dozen unique tests, each with important clinical application to newborns and pediatric patients. Cell lysis, plasma preparation, magnetic bead washing, thermocycling, incubation, and many other essential functions were all performed on the cartridge without any user intervention. The resulting assays demonstrate performance comparable to standard clinical laboratory assays and are economical due to the reduced hands-on effort required for each assay and lower overall reagent consumption. These capabilities allow a wide range of assays to be run simultaneously on the same cartridge using significantly reduced sample volumes with results in minutes.

Effectiveness of minimum retesting intervals in managing repetitive laboratory testing: experience from a Croatian university hospital

Introduction

Inappropriate laboratory retesting can be addressed by implementing minimum retesting intervals (MRI). The aim of our study was to assess the effectiveness of the implemented MRI protocol for inpatients.

Materials and methods

Minimum retesting intervals were applied for 53 laboratory tests. The overall reduction of test requests, reduction in charges and reagent cost savings, frequency of MRI alert appearance as well as the rate of MRI acceptance and ignorance were calculated for a one-year period. Reasons for violating the MRI rule, hospital departments that contributed mostly to MRI rule violation, and the frequency of MRI violations between routine and emergency laboratory were evaluated.

Results

During the one-year period, 106,780 requests violated the MRI rule, which corresponds to 14.8% of all requests received. 13,843 requests were cancelled, yielding a 1.9% reduction of requested tests. High-volume tests, namely complete blood count, C-reactive protein, alanine aminotransferase, gamma-glutamyltransferase and total bilirubin, accounted for 65% of all generated alerts and had the highest alert ignorance (>85%). The highest cancellation rate was observed for tumor markers and autoimmunity tests, for most being at least 50%. Annual charge reduction was 62,641 EUR while reagent cost savings were 11,408 EUR. Tests performed in the emergency laboratory had a higher alert appearance than the same routine tests. The most common reason for MRI violation was clinical justification based on the patient's condition. Most frequently ignored MRI alerts were in the intensive care unit.

Conclusion

MRI implementation showed limited effectiveness in reducing testing repetition and achieving financial savings, yet provided the basis for future improvements.

Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review

BACKGROUND

As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia.

METHODS

We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis.

RESULTS

We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline.

CONCLUSIONS

Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.

Optimizing Measurement of Vascular Endothelial Growth Factor in Small Blood Samples of Premature Infants

To establish a method that allows for the reliable assessment of vascular endothelial growth factor (VEGF-A) concentrations in very small blood samples of preterm infants. Systemic VEGF measurements are important in view of the most appropriate Anti-VEGF drug to be used for the treatment of acute retinopathy of prematurity (ROP). Cord blood samples from preterm (n = 6) infants, blood samples from preterm infants with treatment requiring ROP (n = 12), and blood samples from healthy adults (n = 10) were collected. Serum, citrate plasma, and serum from recalcified citrate blood were obtained. Levels of VEGF-A and platelet factor-4 (PF-4) were quantified by ELISA or AlphaLISA immunoassay. VEGF-A levels could be detected by both assays, with the AlphaLISA generating slightly lower levels in healthy adults, but not in cord blood of preterm infants. In plasma samples, VEGF levels ranged from non detectable to 181 pg/ml. PF-4 concentrations were between 0.16–3.88 µg/ml. Values of VEGF-A and PF-4 in serum and recalcified serum were significantly higher compared to plasma through the release of these cytokines after platelet activation. In plasma samples of infants with ROP, VEGF-A could always be detected and its values ranged from 19.50 to 245.91 pg/ml and PF-4 concentrations were between 0.1 and 3.3 µg/ml. Using the AlphaLISA kit, we were able to detect VEGF in small sample volumes (5 µl plasma or serum/well) in premature infants with treatment requiring ROP and to monitor platelet activation by PF-4 detection. Minimal blood probe volumes reduce phlebotomy losses avoiding the risk of iatrogenic anemia, thus allowing close monitoring of the cytokine levels in these very fragile infants.

Implementation of point-of-care testing in a pediatric healthcare setting

Point-of-care testing (POCT) refers to testing performed outside the clinical laboratory near the patient or at the site of patient care. This could be in critical care settings like the intensive care unit (ICU) and emergency department (ED) or primary care settings like physician offices where testing is performed by nonlaboratory personnel. POCT circumvents several steps in central laboratory testing including specimen transportation and processing resulting in faster turnaround times. Provider access to rapid test results at the site of patient care allows for prompt medical decision making which can lead to improved patient outcomes, operational efficiencies, patient satisfaction, and even cost savings in some cases. In addition to providing results rapidly, POCT devices have small specimen volume requirements compared to central laboratory tests making POCT particularly attractive for pediatric healthcare settings. The availability of published reports on the impact of POCT implementation in pediatric care are helpful resources when evaluating the clinical necessity of POCT prior to implementation. Even though several studies have shown advantages to implementing POCT in different pediatric settings, it is important to note that limitations exist that might limit the utilization of certain POCTs in some pediatric populations. So, it is important that these limitations and the analytical performance of a test are considered while keeping the target patient population in mind. Since POCTs are performed by non-laboratory staff who are not trained laboratory personnel, one challenge with POCT is maintaining regulatory compliance and quality assurance. It is therefore important that regulatory and quality assurance programs be put in place prior to implementing POCT in the pediatric hospital. With advances in POCT technology, most POCT devices have the capability to interface to the laboratory information system (LIS) and electronic medical record (EMR). POCT device interfacing allows for improved compliance to regulatory and quality assurance standards. Maintaining a cost efficient POCT program is becoming increasingly important as hospitals and healthcare systems are undergoing consolidation and harmonization. This includes assessing the clinical and operational benefit of POCT before implementation and inventory management to ensure minimal reagent wastage. This review discusses these different considerations when implementing POCT with a focus on the pediatric healthcare setting.

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

The need for non- or minimally-invasive biomonitoring strategies and the development of pharmacokinetic/pharmacodynamic models for quantification

Advancements in Exposure Science involving the development and deployment of biomarkers of exposure and biological response are anticipated to significantly (and positively) influence health outcomes associated with occupational, environmental and clinical exposure to chemicals/drugs. To achieve this vision, innovative strategies are needed to develop multiplex sensor platforms capable of quantifying individual and mixed exposures (i.e. systemic dose) by measuring biomarkers of dose and biological response in readily obtainable (non-invasive) biofluids. Secondly, the use of saliva (alternative to blood) for biomonitoring coupled with the ability to rapidly analyze multiple samples in real-time offers an innovative opportunity to revolutionize biomonitoring assessments. In this regard, the timing and number of samples taken for biomonitoring will not be limited as is currently the case. In addition, real-time analysis will facilitate identification of work practices or conditions that are contributing to increased exposures and will make possible a more rapid and successful intervention strategy. The initial development and application of computational models for evaluation of saliva/blood analyte concentration at anticipated exposure levels represents an important opportunity to establish the limits of quantification and robustness of multiplex sensor systems by exploiting a unique computational modeling framework. The use of these pharmacokinetic models will also enable prediction of an exposure dose based on the saliva/blood measurement. This novel strategy will result in a more accurate prediction of exposures and, once validated, can be employed to assess dosimetry to a broad range of chemicals in support of biomonitoring and epidemiology studies.