Packed Red Blood Cell Transfusion and Intestinal Blood Flow in Preterm Neonates

June 18, 2014 updated by: Aaron Pitzele, MD, St. Louis University

Packed Red Blood Cell Transfusion and Intestinal Blood Flow in Preterm Infants

The purpose of the study is to determine whether packed red blood cell (PRBC) transfusion affects intestinal blood flow of premature infants during feedings and if so, whether return of normal intestinal blood flow pattern occurs within 48 hours of blood transfusion.

Abnormal intestinal responses to the feedings (insufficient postprandial blood flow increase in order to digest given feeding volume or overall decrease of intestinal blood flow) may predispose infants to feeding intolerance and to serious intestinal disease called necrotizing enterocolitis (NEC).

Patent ductus arteriosus (PDA) is a relatively common heart condition found in young preterm infants that can lead to decreased blood flow in different organs, including intestines. Thus, the determination of the presence or absence of PDA is an important part of the study, since it can be a relevant confounding variable.

In this study, the investigators will assess intestinal blood flow by using sonogram to measure velocity through the superior mesenteric artery (SMA), the artery supplying most of the intestine, both pre- and 45 minutes post feeding. The investigators will also use echocardiogram to determine the presence or absence of PDA. Each set of measurements will be done immediately before and after the transfusion, and again 24 and 48 hours after the transfusion.

Specific Hypothesis: The investigators hypothesize that infants will have attenuated postprandial blood flow velocities in immediate posttransfusion state when compared to the pretransfusion values. The investigators further hypothesize that normal, pretransfusion postprandial blood flow velocities will be achieved 48 hrs after the blood transfusion.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Necrotizing enterocolitis (NEC) is the death of intestinal tissue. It most often affects premature or sick babies. NEC occurs when the lining of the intestinal wall dies and the tissue falls off. NEC is a known complication of prematurity with high morbidity and mortality. About 7 to 13% of all very low birth weight infants admitted to Neonatal Intensive Care Units (NICU) develop NEC, with mortality ranging from 10 to 44% (1,2,3).

NEC is considered a multifactorial disorder converging on a common final clinical presentation associated with several etiologic mechanisms, including ischemia (eg reperfusion), infection (eg, gut colonization), mechanical injury (eg, viscosity, embolic), iatrogenic factors (eg catheters, excessive enteral feeding), and immunological barrier dysfunction (1,13,4,5) To date, there is no single, unifying consensus on causation (6).

Newly, the association between NEC and Packed Red Blood Cell (PRBC)transfusion has been a subject of recent debate. Several retrospective studies report increased incidence of NEC 22 hrs (7) or 48-72 hrs after PRBC transfusion (8) and increased odds of NEC development within 48 hrs posttransfusion (9). Singh, measuring the strength of association between the NEC and PRBC transfusion describes the association as strong < 24hrs, less strong < 48 hrs and absent at 96 hrs (10). Importantly, the majority of the infants in these studies were stable premature neonates on full enteral feeds, who decompensated and developed NEC after being transfused.

Based on poor or no evidence, many NICUs are implementing policy not to feed premature infants during the blood transfusion (11). A small recent prospective trial (8) reported decreased incidence of NEC (from 5.3 to 1.3%) when feeds are withheld during the transfusion. Similarly, the limited investigation of the superior mesenteric artery (blood vessel that supplies the greatest volume of blood to the intestinal tract) blood flow velocities (SMA BFV) revealed that the expected post-prandial increase in SMA BFV disappeared following the PRBC, placing the fed neonates receiving blood transfusion at higher risk for NEC (12).

This initial study had several major limitations, such as enrolling larger and more mature preterm neonates at lesser risk for PRBC transfusion related NEC, excluding infants with patent ductus arteriosus (PDA), common clinical condition in preterm neonates, losing 11 out of 22 patients for follow up studies (hence "normalization" of post-prandial blood flow velocities and finding potentially safe time point for feeds reintroduction could not be suggested by the study results) and using relatively less commonly transfused PRBC volumes over longer period of time.

In this study, the investigators intend to further their understanding of the hemodynamic consequences of PRBC transfusion in very low birth weight (VLBW) neonates by evaluating pre-and post-prandial SMA BFV in neonates who are not fed during the transfusion at different time points and correlate those with relevant clinical outcome measures. The investigators anticipate that the results from this study will be used by clinicians to help guide them in making decisions regarding the safety of administering PRBC transfusion in VLBW neonates.

Study Type

Observational

Enrollment (Actual)

25

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Missouri
      • St Louis, Missouri, United States, 63104
        • Cardinal Glennon Children's Hospital / Saint Louis University

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

No older than 3 months (Child)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Sampling Method

Non-Probability Sample

Study Population

Preterm neonates (≤1500 grams of birth weight) of singleton and multiple births who are admitted to the NICU at Cardinal Glennon Children's Hospital and who are tolerating ≥ 20 ml/kg/day of feeding volume run over 30 minutes or less; both males and females of all ethnic groups.

Very Low Birth Weight (VLBW) neonates will be studied since morbidities such as transfusion related acute gastrointestinal injury and/or necrotizing enterocolitis, PDA and feeding intolerance most frequently occur in this group.

Because the need to ensure parental comprehension prior to consent documentation, parents who, in the judgement of the attending physician and/or research team members, do not have an adequate command of the English language will not be invited to participate in the study.

Description

Inclusion Criteria:

  • birth weight ≤ 1500 gm
  • singleton and multiple gestation
  • small and appropriate birth weight for gestational age
  • tolerance of ≥ 20 ml/kg/day of feeding volumes over 30 minutes or less
  • at least 14 days of age and ≤ 35 6/7 weeks corrected gestational age at time of transfusion.
  • Expected age range of 0-3 months is based on expected age of extremely low birth weight infants at limit (35 6/7 weeks) of corrected gestational age.

Only those infants who receive transfusion at < or equal to 35 weeks will undergo the PDA/SMA and BFV procedures and have data included in analysis.

Exclusion Criteria:

  • major congenital or chromosomal anomalies
  • presence of congenital heart disease (minus patent ductus arteriosus
  • presence of shock
  • presence of vasopressor use
  • presence of severe lung disease
  • concurrent treatment with antibiotics for sepsis
  • history of NEC Bell stage 2 or greater
  • Infants experiencing changes in vital signs or oxygen level drop needing intervention (such as oxygen increase or stimulation) will have studies discontinued and will be excluded from further analysis.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Cohorts and Interventions

Group / Cohort
Intervention / Treatment
blood transfusion group
Procedure: ultrasound
sonographic evaluation of intestinal blood flow

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Assessing intestinal blood flow by comparing superior mesenteric artery velocities in preterm neonates before and after packed red blood cell transfusion using sonogram.
Time Frame: Measurements are obtained both before and 45 minutes after feeding prior to transfusion; again before and after feeding after transfusion and again at 24 and 48 hours after the transfusion.
Prospective investigation of pre- and post-prandial (45 minutes after feeding completion) SMA BVF in preterm neonates before and after blood transfusion. The pretransfusion SMA BFV measurements (pre- and post-prandial) are done during the last feeding before the transfusion; the postransfusion SMA BFV (pre- and post-prandial) measurements are done during the first feeding immediately following the blood transfusion and again during the feedings 24 and 48 hrs after the transfusion (Total of 8 SMA BFV assessments).
Measurements are obtained both before and 45 minutes after feeding prior to transfusion; again before and after feeding after transfusion and again at 24 and 48 hours after the transfusion.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
To determine whether packed red blood cell transfusion affects patent ductus arteriosus status of the subjects using Echocardiogram to determine the presence or absence of PDA.
Time Frame: Each set of measurements will be done immediately before and after the transfusion, and again 24 and 48 hours after the transfusion.
Before each SMA BFV measurement prior to feeding, the investigators will determine the presence or absence of PDA, since the presence of PDA can affect SMA BFV (total of 4 PDA studies for each enrolled subject).
Each set of measurements will be done immediately before and after the transfusion, and again 24 and 48 hours after the transfusion.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

St. Louis University

Investigators

  • Study Director: Thomas Havranek, MD, Saint Louis University, Cardinal Glennon Children's Hospital
  • Principal Investigator: Aaron Pitzele, MD, Saint Louis University, Cardinal Glennon Children's Medical Center

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

December 1, 2011

Primary Completion (Actual)

August 1, 2013

Study Completion (Actual)

January 1, 2014

Study Registration Dates

First Submitted

June 1, 2012

First Submitted That Met QC Criteria

June 21, 2012

First Posted (Estimate)

June 26, 2012

Study Record Updates

Last Update Posted (Estimate)

June 20, 2014

Last Update Submitted That Met QC Criteria

June 18, 2014

Last Verified

June 1, 2014

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • '20969

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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