Red blood cell transfusion-related necrotizing enterocolitis in very-low-birthweight infants: a near-infrared spectroscopy investigation

Abstract

Background: Recent evidence suggests that antecedent red blood cell (RBC) transfusions increase the risk for necrotizing enterocolitis (NEC), the most common gastrointestinal emergency encountered by very-low-birthweight (VLBW) infants. The underlying mechanism for this association is unknown. Altered oxygenation of the mesenteric vasculature during RBC transfusion has been hypothesized to contribute to NEC development and was investigated in this study.

Study design and methods: Oxygenation patterns among four VLBW infants who developed transfusion-related NEC (TR-NEC) were compared to four VLBW infants with similar gestational age who were transfused but did not develop NEC (non-NEC). Cerebral and mesenteric patterns were recorded before, during, and 48 hours after RBC transfusion using near-infrared spectroscopy (NIRS) technology. Percentage change from mean baseline regional oxygen saturation values and cerebrosplanchnic oxygenation ratios were analyzed.

Results: All TR-NEC infants (24-29 weeks' gestation; 705-1080 g) demonstrated greater variation in mesenteric oxygenation patterns surrounding transfusions than non-NEC infants (27.6-30 weeks' gestation; 980-1210 g). TR-NEC infants received larger mean volumes of total blood (27.75 ± 8.77 mL/kg) than non-NEC infants (15.25 ± 0.5 mL/kg).

Conclusion: Wide fluctuation and decreases in mesenteric oxygenation patterns are more pronounced in TR-NEC infants, especially before TR-NEC onset, compared to non-NEC infants. Greater total volume of infused blood was associated with TR-NEC in preterm infants. Using NIRS, larger prospective studies are needed to further evaluate potential risk factors for NEC in this high-risk population.

Conflict of interest statement

Conflict of Interest Statement: The authors declare that they have no conflicts of interest relevant to the manuscript submitted to Transfusion.

© 2013 American Association of Blood Banks.

Figures

Figure 1

Mesenteric Mean Percentage Change from Baseline: Medical TR-NEC Infants. This graph illustrates the wide mesenteric oxygenation fluctuations above and below baseline measurements during and subsequent to each transfusion event and further reveals decreased oxygenation immediately prior to TR-NEC onset and subsequent increased patterns at the time of TR-NEC onset. Infant 1 received two half-volume PRBC transfusions (7.5ml/kg each) separated by 12 hours. Infant 2 received two full volume (15ml/kg) PRBC transfusions separated by 21 hours. Infant 1 had NIRS monitor removed during resuscitation and transfer to NICU (time point 1 hour after 2nd transfusion). Tx, transfusion; TR-NEC, transfusion-related necrotizing enterocolitis; Mid-Tx, time at which 50% of total volume had infused; * enteral feeding given during specified time frame; 0 = baseline; NEC, onset of TR-NEC.

Figure 2

Surgical TR-NEC Infants Percent Change from Baseline Means. This graph illustrates mesenteric oxygenation patterns of infants that developed surgical TR-NEC. Both infants received two full volume PRBC transfusions; infant 3 transfusions separated by 67 hours, and infant 4 separated by 24 hours. Infant 3 demonstrated an immediate large and persistent decline in oxygenation (−69%) immediately following the initiation of the 1st full volume transfusion (20ml/kg) which persisted until gastrointestinal perforation developed 38.5 hours after the conclusion of the second full volume (20ml/kg) PRBC transfusion. Wide fluctuations in mesenteric oxygenation were observed in infant 4 prior to and following the development of Bell’s Stage IA TR-NEC symptoms at the beginning of the 2nd full volume transfusion (15ml/kg). Enteral feedings were held for 18 hours and then resumed. Tx, transfusion; TR-NEC, transfusion-related necrotizing enterocolitis; Mid-Tx, time at which 50% of total volume had infused; *enteral feeding given during specified time frame; 0 = baseline.

Figure 3

Mesenteric percent change from baseline mean for Non-NEC Infants. Infant 5 received two half-volume PRBC transfusions (7.5ml. kg each) separated by 12 hours; all other infants received one full volume PRBC transfusion. Overall increased oxygenation in mesenteric oxygenation was prevalent among the non-NEC infants, although wide mean fluctuation was apparent in infant 6, 7 and 8 (closely resembling surgical TR-NEC infant 4). Six hours post-transfusion, infant 6 demonstrated a dramatic decline in oxygenation that coincided with severe bradycardic and apneic episodes, which improved following elective intubation. Tx, transfusion; Mid-Tx, time at which 50% of total volume had infused; *enteral feeding given during specified time frame; 0 = baseline.