labs

Jolie, BSN · Aug 29, 2003

You are probably on the right track with both theories. Preemies are sometimes given erythropoetin to enhance thier ability to manufacture RBCs, in an effort to reduce the need for transfusions. While this baby may not have suffered an acute blood loss, he may still have suffered a significant loss over time in the form of blood draws for labs. Most NICUs keep a running total of each baby's negative blood balance to help evaluate when a transfusion is appropriate. Also, remember that the baby is growing rapidly, and it is difficult for a preemie to manufacture enough RBCs to keep up with growth, even if they are not losing much blood to labs.

NICU_Nurse, BSN, RN · Aug 29, 2003

This baby *could* certainly have suffered an acute blood loss- in fact, if the Hgb and Hct dropped suddenly (from one day to the next), I'd certainly be investigating whether or not this baby had a cranial bleed (the germinal matrix in infants is very delicate, and it doesn't take much at all to stimulate a cranial hemmorrhage- could be that the baby was inverted- think Trendelenburg position, could be that constantly withdrawing from an arterial catheter changed the cranial pressure rapidly and stimulated a bleed, etc.).

Also, you're correct about preemies not able to stimulate RBC production at an ideal rate, and Jolie is absolutely right about babies losing blood from blood draws. Infants, particularly those who are already ill or are being investigated for septic conditions lose a tremendous amount of their blood volume over the course of a few days. Between lab draws Q AM and Q 1-4 hour/PRN blood gas draws, blood cultures, etc. these babies often end up losing more blood than they can replace.

Furthermore, infants who are solely breastfed have an increased risk of anemia, especially if their milk is not being supplemented with Human Milk Fortifier powder. If mom is not supplying what the baby needs via breastmilk and there is no order to supplement the milk, the baby is at risk for iron-defeciency anemia.

Low Hgb could also be a sign that the body is hemolyzing the red blood cells secondary to a larger problem- infection or an organ defeciency. The anemia could be drug induced, where a medication the baby is receiving could have the side effect of hemolysis. This could be a known side effect or an adverse effect- depends on the drug (Penicillins and cephalosporins can cause this, I believe).

If the baby is male, he could have hemophilia, which could cause these lab results. Also, if the baby has been on NEC precautions and suddenly there is a dramatic shift in the Hgb/Hct, I'd be wondering if there was organ perforation involved.

So basically, it's anything BUT a no-brainer! LOL! It could be a number of things, depending on the particular infant.

Edited to add: I just thought of something else- maybe someone else could answer this one? If your baby is experiencing FVO, wouldn't the blood be dilute and thus reveal a lower Hct/Hgb? I'm not sure about this last one; hopefully someone out there would know! :)

SheaTabRN · Aug 29, 2003

>>

That is very true in adults!

As far as the erythropoietin question from the RN student goes... there is an excellent article at emedicine.com about neonatal anemia. I will include the link here. But the interesting thing about premature neonates that is so very different from adults is that even by the end of gestation the liver is the major organ of erythropoietin (EPO) production. AND... only at 32 weeks gestation does the bone marrow take an active role in RBC production. The article also mentions that the degree of hypoxia/anemia required to stimulate the production of EPO in the liver is much higher than that of EPO produced by the kidneys.

http://www.emedicine.com/ped/topic2629.htm

"As a result, new RBC production in the extremely premature infant (whose liver remains the major site of EPO production) is blunted despite what may be marked anemia. "

"the average life span of a neonatal RBC is only one half to two thirds that of the RBC life span in an adult. Cells of the most immature infants may survive only 35-50 days."

The thing about these litttle babies that I have humbly learned is that they are a totally different animal than the adult human. I can honestly say that very little I learned in nursing school could have prepared me for this! Anywho... hope this helps. AND... good luck in nursing school.

Tab:) ;)

prmenrs, RN · Aug 29, 2003

Originally posted by SheaTabRN
The thing about these litttle babies that I have humbly learned is that they are a totally different animal than the adult human. I can honestly say that very little I learned in nursing school could have prepared me for this! Anywho... hope this helps. AND... good luck in nursing school.
Tab:) ;) [/b]

And that is one reason that new grads who want to do NICU should go right into it and NOT do that sacred "year in med-surg".

Premies don't even resemble term newborns sometimes, nor do they resemble bigger babies/children. They are a whole 'nother species. Good thing they're cute!

What they can do for you is to make you REALLY learn every bit of physiology and biochem you ever knew. Pre-reqs are very relevant!

Term newborns become increasingly anemic until they reach a 'nadir' @ about 3 months, and then their bone marrow wakes up and kicks into gear. Premies have trouble dealing w/RBCs--any premie I've ever met needs to get 'lit', often more than once--Epoetin is a major advancement; given w/enough Fe [if they can't tolerate it p.o., IronDextran can be given IV], a lot of kids now never need a blood transfusion, despite 3month stays.

nurse09/77--you're doing great to look for a REASON the kid is anemic. Keep up the good work!

NICU_Nurse, BSN, RN · Aug 30, 2003

Sandi, I've never given Epoetin to an infant- in fact, I'm quite excited to hear that it's used in infants (my only recollection of this is from nursing school). How effective is this with the babies? The ELBW's? I'm going to have to look this up. I wonder why we never did this.

gypsyatheart · Aug 30, 2003

Originally posted by prmenrs
And that is one reason that new grads who want to do NICU should go right into it and NOT do that sacred "year in med-surg".

Premies don't even resemble term newborns sometimes, nor do they resemble bigger babies/children. They are a whole 'nother species. Good thing they're cute!

What they can do for you is to make you REALLY learn every bit of physiology and biochem you ever knew. Pre-reqs are very relevant!

Term newborns become increasingly anemic until they reach a 'nadir' @ about 3 months, and then their bone marrow wakes up and kicks into gear. Premies have trouble dealing w/RBCs--any premie I've ever met needs to get 'lit', often more than once--Epoetin is a major advancement; given w/enough Fe [if they can't tolerate it p.o., IronDextran can be given IV], a lot of kids now never need a blood transfusion, despite 3month stays.

nurse09/77--you're doing great to look for a REASON the kid is anemic. Keep up the good work!

I could not agree w/you more! 10 yrs in L&D/Peds really did not prepare me for NI, it's like you have to learn/re-learn everything! It is fun though, and exciting, very glad I'm working w/these little ones!

prmenrs, RN · Aug 30, 2003

We would give the shots q.o.d., on 'even' days--that way Pharmacy would only have to open a few vials--cheaper. It's dosed by wt, of course, each kid only gets a tiny bit. So small you can use the triceps area.

It used to be that any really small baby would get at least 1 or 2 transfusions--or more. W/the Epo and Fe, they may not need any transfusions. I think that is so great. Even w/irradiating the blood, using only one donor, screening for CMV, etc., who knows what they might find out in the next few years that we were putting the babies @ risk for?