Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Electrostatic potential of the DNA binding surface of hApe1 and the corresponding surface area of Crc

<p>. The color coded electrostatic surface potential of hApe1 (<b>A</b>) and Crc (<b>B</b>) was drawn using the Adaptive Poisson-Boltzmann Solver package <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0064609#pone.0064609-Baker1" target="_blank">[37]</a> within PYMOL <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0064609#pone.0064609-DeLano1" target="_blank">[36]</a>. The electrostatic potential ranges from −5 (red) to +5 (blue) kT/e. The path of the DNA is shown in orange for hApe1 (<b>A</b>) and superimposed on Crc (<b>B</b>).</p

Structural comparison of Crc with AP endonucleases.

<p>(<b>A</b>), Superposition of the ribbon diagrams of Crc and its ortholog hApe1. Crc and hApe1 are colored in green and cyan, respectively. The positions of amino acid residues corresponding to active site residues in AP proteins are depicted in orange. (<b>B</b>), The catalytically active site of hApe1 (PDB accession code 1DE8) (cyan) is superposed with the corresponding area of Crc (green). (<b>C</b>), Sequence alignment of Crc with hApe1 (<i>Homo sapiens</i>) and Nape (<i>Neisseria meningitidis</i>). The four highly conserved residues located at the catalytically active site are highlighted in pink.</p

Electrophoretic mobility shift assays using CrcŹ RNA.

<p>Electrophoretic mobility shift assay of 10 nM 5′-end labeled CrcZ′ RNA with increasing amounts of His-Crc purified from the <i>E. coli</i> strain Rosetta™ (DE3)(pLysS pETM14lic-His₆Crc) by one-step NAC (<b>A</b>) and by one-step NAC followed by SEC (<b>B</b>), respectively. EMSA assay employing the His-Crc protein purified from the <i>P. aeruginosa</i> strain PAO1(pME9670) by one-step NAC (<b>C</b>), the protein eluate obtained after one-step NAC from strain Rosetta™ (DE3)(pLysS, pETM14lic) (mock; no Crc protein) (<b>D</b>) and the His-Crc protein from the <i>E. coli hfq-</i> strain JW4130(pME9670) by one-step NAC (<b>E</b>). Lane 1, no protein was added to labeled <i>CrcZ`</i> RNA. Lanes 2-4, the protein fractions were added in 50, 100 and 200-fold molar excess over labeled RNA. In the case of the mock preparation (<b>D</b>), the same amount of protein was added to RNA as in the experiments shown in panels <b>A</b>, <b>B</b> and <b>C</b>.</p

Purity of different His-Crc preparations and contamination with Hfq.

<p>(<b>A</b>) 12% SDS-polyacrylamide gel stained with Coomassie brilliant blue after electrophoretic separation of marker proteins (M; the numbers denote molecular masses in kD), His-Crc purified by one-step NAC (lane 1), His-Crc purified by NAC followed by SEC (lane 2), NAC eluate obtained from the mock control (no Crc protein) (lane 3), His-Crc purified by one-step NAC from the <i>hfq-</i> strain (lane 4) and His-Crc purified by one-step NAC from PAO1 (lane 5). (<b>B</b>) Immunodetetction of Hfq. The samples shown in A, lanes 1–3, were 5-fold concentrated and subjected to western-blotting using Hfq-specific antibodies.</p

Data collection and refinement statistics.

a<p>Values in parentheses are for the highest resolution shell.</p>b<p></p>c<p></p>d<p></p><p>Where is the mean intensity of multiple observations of the symmetry-related reflections, N is the redundancy.</p>e<p></p>f<p>R_free is the cross-validation R_factor computed for the test set of reflections (5%) which are omitted in the refinement process.</p

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (&gt;30% decrease in blood pressure) or reduced oxygenation (SpO2 &lt;85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants