Transfusion associated NEC

[essT]

What is your unit's policy with regards to making babies NPO for blood transfusions?

I recently transferred to a level III NICU. For the two years prior to my arrival, our unit would make babies NPO (starting or increasing IV fluid) for two hours prior to blood, transfuse, and keep NPO two hours after completion. Our neos compared the unit's data from this period to years prior and saw no change in NEC incidence but an increase in hypoglycemic episodes.

Because of this, they decided to go back to the old way of continuing feeds throughout the transfusion. This was right when I began working in the unit. Within a couple months we've had three babies die from NEC -- all PRBC transfused within the past 24 hours, all previously fed breast milk exclusively, all ex-24 weekers.

I thought keeping kids NPO was standard practice. From what I can tell, evidence points pretty strongly to the existence of TANEC, as well as its high(er) rate of mortality than NEC that's not transfusion associated. I am frankly surprised that two years worth of data from our little 40 bed unit is being valued over many years of research in academic settings and some of the meta analyses that come up at the top of every search.

Is there something I'm overlooking? It's not like I want my babies to experience hypoglycemia, but a bolus or some tweaking of IVF seems a whole lot less dire than NEC. Looking for input. Like I said, I'm pretty new to this.

[RNNPICU, BSN, RN]

I wonder if it had anything to do with volume of blood given. For example, if baby is receiving X amount of fluid (IV, formula, etc) in addition to blood, there may be concern for fluid overload

[NicuGal, MSN, RN]

We have never made them NPO. If we only have one peripheral line and we can't start another for some reason we check glucoses every 30 minutes and restart IVF as needed for an hour. If we have a PICC, we start a peripheral and run our main IVF at half rate and check a glucose at one hour, if the kid needs the volume then full rate. There is no reason to let them be hypoglycemic for the duration if the transfusion.

We run our blood over 2-3 hours depending on the volume. If they are prone to fluid overload, they get a dose of Lasix after.

In near 30 years I can say I have not seen a correlation between NEC and blood transfusions.

[labordude, BSN, RN]

With TANEC or TRAGLI (take your pick), the correlation is highest when the baby starts off with a very low HCT. The evidence suggests that babies with HCTs below 25 are at highest risk for injury, thus the big push to not let them get that low in the first place. We recently made a change in our transfusion policy where we feed the baby, give them the blood over 3 hours at the NEXT feeding time, skip the feed after that and then restart. It is the RN discretion on whether or not to check a d-stick as there is evidence that PRBC transfusion provides a GIR between 4-7mg/kg/min which is more than enough for most babies. That being said, I have never had a patient in 9 years where I felt that their NEC was related to a PRBC transfusion.

[NicuGal, MSN, RN]

Very good points. How low were the hcts? If they have really low crits, the blood is going to be shunted to more vital organs and you could see feeding intolerance and gut symptoms. Good thought.

[thatsthekeyRNC]

We keep the babies NPO for 3 hours before, during, and 3 hours after transfusions but fluids are running before and after so there aren't issues with hypoglycemia. If the baby has a PICC, whatever fluids they normally get will continue to run at a lower rate while the blood is running and then switch back after it's done.

[rnkaytee]

With TANEC or TRAGLI (take your pick), the correlation is highest when the baby starts off with a very low HCT. The evidence suggests that babies with HCTs below 25 are at highest risk for injury, thus the big push to not let them get that low in the first place. We recently made a change in our transfusion policy where we feed the baby, give them the blood over 3 hours at the NEXT feeding time, skip the feed after that and then restart. It is the RN discretion on whether or not to check a d-stick as there is evidence that PRBC transfusion provides a GIR between 4-7mg/kg/min which is more than enough for most babies. That being said, I have never had a patient in 9 years where I felt that their NEC was related to a PRBC transfusion.

This is exactly what we do. It took forever for us to change our policy but we finally did a few years ago.

[essT]

Thank you everyone for your thoughts. I appreciate the insight!

NicuGal and nicuguy -- As for the Hcts, two of the transfusions were routine per our unit protocol. I don't have exact values, but as far as I know they weren't drastically low (definitely not

thatsthekeyRN -- that's what our old policy was, except with scheduled accuchecks.

[SteveNNP, MSN, NP]

As a general rule, we make babies NPO 4 hours before, during, and 4 hours after transfusion. We start an additional line to deliver IVF/TPN during the transfusion.

We currently have research in progress looking at the age of donor blood at time of transfusion in relation to NEC development. Another thought to consider is a chicken/egg issue. If the baby is so anemic that oxygen delivery is compromised, ischemia occurs leading to NEC, maybe it's that and not the transfusion itself?

[NicuGal, MSN, RN]

I asked our docs about this and they also stated that it is not the blood transfusion itself, but the anemia that causes the gut problems. Most of our kids who get blood are pretty sick to start with, we rarely give blood to kids anymore since starting our Epogen protocol. But if

they are feeding we don't stop their

feeds.

[babiesRmylife]

Currently: If infants were eating before the transfusion then they will NOT be made NPO at this time in our unit.

There has been much talk about making ALL babies NPO for X amount of time before & after transfusions because they think low blood counts that require transfusions could be a very early sign of NEC. This has not yet started in our unit, but I think it is in the works & all the fine details are being worked out.

[essT]

"We currently have research in progress looking at the age of donor blood at time of transfusion in relation to NEC development."

Steve--yes, this has been a recently emerging concern with us, too. Anything you can share would be appreciated. It's been tossed around as an idea but no direction as of yet.