The value of carboxyhaemoglobin measured with co-oximetry in diagnosis of haemolysis in newbors

Zlatenica novorojenčka je najpogostejše klinično stanje, s katerim se srečujemo v neonatologiji, saj jo zaznamo pri 60 % novorojenčkov. Čeprav je pojav najpogosteje posledica fizioloških sprememb po rojstvu, je opredelitev drugih možnih razlogov za zlatenico zelo pomembna, saj v primeru hemolize, ki je pogost razlog patološke zlatenice, pričakujemo visoke vrednosti bilirubina in anemijo. Visoke vrednosti bilirubina so za novorojenčka zaradi toksičnega delovanja bilirubina na živčne celice potencialno nevarne. Iz ne povsem pojasnjenih razlogov je nevrotoksičen učinek bilirubina v prisotnosti hemolize povečan, zato hemolizo uvrščamo med rizične dejavnike za razvoj akutne in kronične bilirubinske encefalopatije. Dokazovanje hemolitičnega dogajanja je pri novorojenčku zato pomembno tako z vidika pojasnjevanja etiologije zlatenice kot njene obravnave. Potrditev hemolize je pri novorojenčkih lahko težavna. Uvedba zanesljivega in enostavnega diagnostičnega testa za dokaz hemolize bi bila zato dobrodošla pridobitev v obravnavi zlateničnega novorojenčka. Pri razgradnji hema nastaja ogljikov monoksid (CO), ki se veže na hemoglobin in tvori karboksihemoglobin (COHb). Vrednost COHb v krvi je zato indeks endogeno nastalega CO in hemolize. Določitev COHb z oksimetrijo je hitra, enostavna in široko dostopna laboratorijska metoda, ki za analizo potrebuje majhno količino krvi. Meritve COHb z oksimetrijo pri novorojenčkih še niso bile ustrezno preučene. Opredelitev pomena določanja COHb z oksimetrijo pri novorojenčku za dokazovanje hemolize je zato zanimiv raziskovalni izziv, h kateremu je bila usmerjena tudi raziskava, predstavljena v doktorskem delu. V uvodnem delu so predstavljeni etiologija fiziološke zlatenice in najpogostejši razlogi za patološko zlatenico ter etiologija in mehanizmi hemolize pri hemolitični bolezni novorojenčka. Poleg tega so povzeti izsledki raziskav, ki pojasnjujejo mehanizem nevrotoksičnega delovanja bilirubina in potrjujejo vlogo hemolize na pojavnost bilirubinske encefalopatije. Pri dokazovanju hemolize se poslužujemo posrednih hematoloških kazalcev hemolize in transfuzijskih testov. V nadaljevanju so pojasnjene klinične dileme ob uporabi hematoloških in specialnih laboratorijskih testov za potrditev hemolize pri novorojenčku. Natančneje je predstavljen proces razgradnje hema in rezultati kliničnih raziskav, ki potrjujejo, da je pri hemolizi tvorba CO povečana, kar lahko dokažemo z merjenjem COHb v krvi ali CO v izdihanem zraku. COHb v kliničnih laboratorijih določamo sprektrofotometrično z oksimetri, v raziskovalne namene pa je bila do sedaj pogosteje uporabljena plinska kromatografija. Hem oksigenaza (HO) je encim, ki katalizira razgradnjo hema. HO-1 izoforma encima je inducibilna, zato uvodoma opredeljujemo teoretične klinične dejavnike, ki lahko povzročijo indukcijo encima in s tem vplivajo na nastajanje CO v telesu in vrednosti COHb. V drugem delu so predstavljene metode in rezultati raziskave, ki je bila sestavljena iz dveh delov. V prvem, prospektivnem delu smo primerjali vrednosti COHb, določene z oksimetrijo, med 18 zaporedno hospitaliziranimi donošenimi novorojenčki s hemolitično boleznijo ploda in novorojenčka zaradi neskladja v sistemu krvnih skupin ABO med materjo in otrokom, 21 donošenimi novorojenčki z zlatenico brez hemolize, ki so potrebovali fototerapijo, ter 47 zdravimi donošenimi novorojenčki. Vrednosti COHb so se med skupinami statistično značilno razlikovale in so bile v skupini novorojenčkov s hemolizo bistveno višje kot v skupini novorojenčkov z zlatenico in v skupini zdravih novorojenčkov (mediana COHb 2,4 % (IQR 1,3) vs. 1,3 % (IQR 0,8) in 1,3 % (IQR 0,2)). Rezultati multivariantne analize so pokazali, da je vpliv hemolize na vrednost COHb pri novorojenčkih od vseh v model vključenih spremenljivk največji in statistično značilen. Diagnostično zanesljivost meritve COHb z oksimetrijo za dokaz hemolize smo ocenili s površino pod ROC-krivuljo (angl. receiver operating characteristic area under the curve, ROC AUC). Rezultati ROC-analize dokazujejo, da je meritev COHb dobra diagnostična metoda za potrditev hemolize pri novorojenčku, saj je bila ROC AUC >0,9, občutljivost in specifičnost v raziskavi določene optimalne razmejitvene vrednosti COHb, ki je bila &#88051,7 %, pa sta bili visoki. V drugem, retrospektivnem delu raziskave smo primerjali vrednosti COHb, določene z oksimetrijo, med 8 novorojenčki s sepso, 37 novorojenčki z dihalno stisko, 16 novorojenčki s hemolizo in 76 zdravimi novorojenčki. Vsi vključeni novorojenčki so bili donošeni. Tudi analiza retrospektivnih podatkov je pokazala, da je COHb statistično značilno višji pri novorojenčkih s hemolizo (mediana COHb otrok s hemolizo je bila 2,4 % (IQR 1,3)), medtem ko razlike v sicer nekoliko višjih vrednostih COHb pri novorojenčkih s sepso in dihalno stisko (mediana COHb 1,45 % (IQR 0,5) in 1,4 % (IQR 0,4)) ter zdravimi novorojenčki (COHb 1,3 % (IQR 0,3)) niso bile statistično značilne. Vrednotenje diagnostične zanesljivosti meritve COHb z oksimetrijo kot testa za potrditev hemolize z ROC-krivuljo retrospektivnih podatkov je potrdilo ugotovitve prospektivnega dela raziskave. Tudi ROC AUC retrospektivnih podatkov je bila visoka (>0,9), optimalna razmejitvena vrednost COHb enaka (&#88051,7 %), občutljivost in specifičnost testa pa visoki, kljub vključitvi otrok s sepso in dihalno stisko v analizo. Odvisnost COHb od postnatalne starosti je bila negativna, saj so vrednosti COHb prve dni po rojstvu pri zdravih novorojenčkih višje. 1. dan po rojstvu je bila povprečna vrednost COHb zdravih novorojenčkov 1,35 %, 7. dan 1,26 % in 14. dan 1,01 %. V razpravi so izsledki doktorske raziskave primerjani z do sedaj znanimi podatki o nastajanju CO in vrednostih COHb, določenih z drugimi laboratorijskimi metodami, pri različnih skupinah novorojenčkov. Vrednosti COHb, določene z oksimetrijo, so pri bolnikih s hemolizo v enakem območju ali nekoliko višje od vrednosti, določenih s plinsko kromatografijo. Tudi primerjava vrednosti COHb pri zdravih novorojenčkih in novorojenčkih s fiziološko zlatenico, določenimi z oksimetrijo ali plinsko kromatografijo, je pokazala podobne ugotovitve, najverjeteje zaradi odsotnosti korekcije COHb za CO v vdihanem zraku pri oksimetrični metodi. Odsotnost korekcije vrednosti COHb za CO v vdihanem zraku zato lahko predstavlja pomembno slabost meritve COHb z oksimetrijo. Kljub temu rezultati raziskave dokazujejo, da je meritev COHb z oksimetrijo dober diagnostični test za potrditev hemolize, saj zelo dobro razlikuje novorojenčke s hemolizo od novorojenčkov, ki hemolize nimajo. Izsledki opravljane raziskave so izhodišče za nadaljnje delo, kot je raziskovanje pomena COHb, določenega z oksimetrijo, pri nedonošenčkih, in vloge COHb v napovedovanju razvoja zlatenice in stopnje hemolize. Rezultati pričujoče raziskave dokazujejo, da je določitev COHb z oksimetrijo dober diagnostični test za potrditev hemolize pri donošenih novorojenčkih in da sta specifičnost in občutljivost testa pri razmejitveni vrednosti COHb &#88051,7 % visoka. Vpliv kliničnih dejavnikov, ki lahko inducirajo HO-1 in s tem vplivajo na vrednosti COHb, je majhen in statistično nepomemben, zato je diskriminativnost testa visoka tudi ob prisotnosti kliničnih dejavnikov, kot sta sepsa in dihalna stiska novorojenčka. Izsledki raziskave predstavljajo izhodišče za uporabo meritve COHb kot diagnostičnega testa za potrditev hemolize pri novorojenčkih.Neonatal jaundice is the most common clinical condition detected in neonatology, as it is present in more than 60 % of neonates. Even though it commonly results from physiologic changes after the birth, the identification of other possible pathologic reasons for icterus is very important. In case of haemolysis, which is a common pathologic factor for neonatal jaundice, high levels of bilirubin and anaemia can be expected. High level of unbound bilirubin can be potentially dangerous for the neonate, since it can cause bilirubin-induced neuronal damage. Haemolysis augments the risk of bilirubin neurotoxicity, but the mechanism of this intensifying effect is uncertain. Consequently, haemolysis represents an important risk factor for development of acute and chronic bilirubin encephalopathy. Confirmation of haemolysis in neonate is therefore very important in terms of explaining the aetiology of the jaundice as well as for its management. Confirming haemolysis in neonates can be very challenging. Introduction of a reliable and simple diagnostic test for the confirmation of haemolysis would therefore be very appreciated in the management of neonatal jaundice. During haeme degradation process carbon monoxide (CO) is produced and bound to haemoglobin, forming carboxyhaemoglobin (COHb). The COHb level in blood can serve as an index of endogenous produced CO and haemolysis. Determination of COHb with CO-oximetry is fast, simple and widely available laboratory method, needing small amount of blood. Determination of COHb with CO-oximeters in neonates hasn’t been adequately studied. Defining the role of COHb measured with CO-oximetry in neonates in evaluation of haemolysis is therefore an interesting research challenge to which the present study was aimed. In the introduction, pathophysiology of physiologic icterus, the commonest reasons for the pathologic icterus and the aetiology and mechanisms of haemolytic process in haemolytic disease of the newborn are presented. Furthermore, the mechanisms of bilirubin induced neurologic damage are discussed and studies confirming the role of haemolysis in the development of bilirubin encephalopathy are presented. In neonates, haemolysis is detected with indirect haematological and specific transfusion laboratory tests. Clinical dilemmas when using these tests in neonates are discussed. Haeme degradation process and the results of clinical studies demonstrating increased formation of CO during haemolysis detected with elevated COHb levels in blood or elevated CO in exhaled breath air are presented. In clinical laboratories COHb is determined spectrophotometrically with CO-oximetry, while for research purposes COHb has been more often determined with gas chromatography. Degradation of haeme is catalysed by haeme oxygenase (HO). The HO-1 isoform is an inducible enzymeclinical factors potentiality influencing the enzyme transcription and consequently influencing the CO formation and COHb levels in the body are discussed. In the second part, methods and results of the study, consisting of two parts, are presented. In the prospective part of the study, the COHb values measured with CO-oximetry in 18 successively hospitalized term neonates with ABO haemolytic disease of newborn, 21 term neonates with jaundice without haemolysis needing phototherapy, and 47 term healthy neonates were compared. The COHb levels were higher in the group of neonates with ABO haemolytic disease of newborn compared to the COHb levels in jaundiced neonates without haemolysis and healthy neonates (median COHb 2.4 % (IQR 1.3) vs. 1.3 % (IQR 0.8) and 1.3 % (IQR 0.2), respectively) and the differences were statistically significant. The results of multivariate analysis showed that haemolysis had the biggest, statistically significant effect on the COHb values compared to other variables included in the model. Receiver operating characteristic (ROC) curve analysis was performed to evaluate a diagnostic value of COHb measured with CO-oximetry as a test for detecting haemolysis in neonates. According to the receiver operating characteristic area under the curve (ROC AUC), the COHb measured with CO-oximetry is a good diagnostic test for confirming haemolysis in neonates, since ROC AUC was more than 0.9, and the sensitivity and specificity of the optimal cut off COHb value, which was in our study set as &#88051.7 %, was very high. In the second, retrospective part of the study, COHb values measured with CO-oximetry in 8 term neonates with neonatal sepsis, 37 term neonates with respiratory distress, 16 term neonates with haemolytic disease of newborn, and 76 healthy neonates were compared. Also, the retrospective analysis of the COHb values measured with CO-oximetry showed statistically significantly higher COHb values in neonates with haemolysis (median COHb was 2.4 % (IQR 1.3)), while the values of COHb between neonates with sepsis and respiratory distress (median COHb 1.4 % (IQR 0.5) and 1.4 % (IQR 0.4), respectively) and healthy neonates (median COHb 1.3 % (IQR 0.3)) were not statistically different, although the median COHb values were slightly higher in neonates with sepsis and respiratory distress compared to healthy neonates. Furthermore, the value of COHb measured with CO-oximetry as a diagnostic test for detecting haemolysis in neonates was evaluated with ROC curve analysis of retrospective obtained data. The ROC curve analysis confirmed the result of the prospective study, since the ROC AUC of retrospective data was high (>0.9), and the specificity and sensitivity of the optimal cut off COHb value, which was the same as in prospective study (&#88051.7 %), were high, even though the neonates with sepsis and respiratory distress were included in the analysis. The correlation between the COHb values and postnatal age was negative, since COHb values are declining in the first days after the birth. The mean COHb value in healthy neonates was 1.35 % on the 1st day after the birth, 1.26 % on the 7th day after the birth, and 1.01 % on the 14th day after the birth. In the discussion, the results of the research are compared with the results of other studies which evaluated the production of CO and COHb values, determined with other laboratory methods, in different groups of neonates. The COHb values measured with CO-oximetry in neonates with haemolysis are similar or slightly higher than the COHb values measured with gas chromatography. The comparison of the COHb values measured with oximetry or gas chromatography in healthy neonates and neonates with jaundice without haemolysis showed similar trend, probably because the oximetry method doesn\u27t correct the COHb value for inhaled air CO. Absence of the correction of COHb value according to the environmental levels of CO seems to be the most important limitation of CO-oximetry, as well as of this study. Nevertheless, the results of the research show that COHb measured with CO-oximetry is a good diagnostic test for detecting haemolysis in neonates, since it performs well in discriminating neonates with and without haemolysis. The results of this research open new possibilities for further work, such as an evaluation of the COHb values measured with CO-oximetry in preterm neonates and an evaluation of the COHb values measured with CO-oximetry in the prediction of icterus and its severity. The results of the study confirm that COHb measured with CO-oximetry is a good diagnostic test for detecting haemolysis in term neonates, and the specificity and the sensitivity of the cut off COHb value of &#88051.7 % are very high. The influence of other clinical factors that may induce HO-1 and influence the COHb values is small and statistically insignificant, therefore the discrimination of the test is high despite the presence of sepsis or respiratory distress, factors that may induce HO-1. The results of the study represent the base for clinical use of COHb measured with CO-oximetry as a diagnostic test for detecting haemolysis in term neonates

Pierre Robinova sekvenca: zdravljenje z nosno-žrelnim tubusom

Pierre Robinova sekvenca je triada, ki jo sestavljajo mikro- in/ali retrognatija, glosoptoza in zapora zgornjih dihal, ki se ji v 90 % pridruži palatoshiza. Pri otrocih s Pierre Robinovo sekvenco sta glavni funkcionalni težavi obstrukcija zgornjih dihal in oteženo hranjenje, ki se kažeta z raznolikimi dihalnimi težavami in slabim pridobivanjem telesne mase. Pri večini bolnikov zadoščajo konzervativni ukrepi, v redkih primerih pa je potrebno kirurško zdravljenje, v najtežjih primerih pa traheotomija. Klinični oddelek za neonatologijo Pediatrične klinike UKC Ljubljana je za zdravljenje novorojenčkov s Pierre Robinovo sekvenco uvedel v slovenski prostor novo metodo, tj. vstavitev nosno-žrelnega tubusa. Ta premosti zaporo zgornjih dihal v višini korena jezika in je ob izmenični zamenjavi strani vstavitve skozi nosnici lahko nameščen daljše obdobje tudi v domačem okolju. Obravnava otrok s Pierre Robinovo sekvenco je multidisciplinarna. Pri obravnavi sodelujejo neonatolog, otorinolaringolog, maksilofacialni kirurg in pulmolog. Gastroenterolog, dietetik in genetik pa so vključeni po potrebi. Članek predstavi klinično sliko otrok s Pierre Robinovo sekvenco, metode zdravljenja in uradno klinično pot obravnave v Sloveniji

Supplemental Iron and Recombinant Erythropoietin for Anemia in Infants Born Very Preterm: A Survey of Clinical Practice in Europe

OBJECTIVES To survey practices of iron and recombinant human erythropoietin (rhEpo) administration to infants born preterm across Europe. STUDY DESIGN Over a 3-month period, we conducted an online survey in 597 neonatal intensive care units (NICUs) of 18 European countries treating infants born with a gestational age of <32 weeks. RESULTS We included 343 NICUs (response rate 56.3%) in the survey. Almost all NICUs (97.7%) routinely supplement enteral iron, and 74.3% of respondents to all infants born <32 weeks of gestation. We found that 65.3% of NICUs routinely evaluate erythropoiesis and iron parameters beyond day 28 after birth. Most NICUs initiate iron supplementation at postnatal age of 2 weeks and stop after 6 months (34.3%) or 12 months (34.3%). Routine use of rhEpo was reported in 22.2% of NICUs, and in individual cases in 6.9%. RhEpo was mostly administered subcutaneously (70.1%) and most frequently at a dose of 250 U/kg 3 times a week (44.3%), but the dose varied greatly between centers. CONCLUSIONS This survey highlights wide heterogeneity in evaluating erythropoietic activity and iron deficiency in infants born preterm. Variation in iron supplementation during infancy likely reflects an inadequate evidence base. Current evidence on the efficacy and safety profile of rhEpo is only poorly translated into clinical practice. This survey demonstrates a need for standards to optimize patient blood management in anemia of prematurity

Platelet transfusion in neonatal intensive care units of 22 European countries: a prospective observational study

BACKGROUND Platelet transfusions are given to preterm infants with severe thrombocytopenia aiming to prevent haemorrhage. The PlaNeT2/MATISSE trial revealed higher rates of mortality and/or major bleeding in preterm infants receiving prophylactic platelet transfusions at a platelet count threshold of 50 × 10$^{9}$/L compared to 25 × 10$^{9}$/L. The extent to which this evidence has been incorporated into clinical practice is unknown, thus we aimed to describe current neonatal platelet transfusion practices in Europe. METHODS We performed a prospective observational study in 64 neonatal intensive care units across 22 European countries between September 2022 and August 2023. Outcome measures included observed transfusion prevalence rates (per country and overall, pooled using a random effects Poisson model), expected rates based on patient-mix (per country, estimated using logistic regression), cumulative incidence of receiving a transfusion by day 28 (with death and discharge considered as competing events), transfusion indications, volumes and infusion rates, platelet count triggers and increment, and adverse effects. FINDINGS We included 1143 preterm infants, of whom 71 (6.2%, [71/1143]) collectively received 217 transfusions. Overall observed prevalence rate was 0.3 platelet transfusion days per 100 admission days. By day 28, 8.3% (95% CI: 5.5-11.1) of infants received a transfusion. Most transfusions were indicated for threshold (74.2%, [161/217]). Pre-transfusion platelet counts were above 25 × 10$^{9}$/L in 33.1% [53/160] of these transfusions. There was significant variability in volume and duration. INTERPRETATION The restrictive threshold of 25 × 10$^{9}$/L is being integrated into clinical practice. Research is needed to explore existing variation and generate evidence for various aspects including optimal volumes and infusion rates. FUNDING Sanquin, EBA, and ESPR

Monitoring and Management of Hemolytic Disease of the Fetus and Newborn Based on an International Expert Delphi Consensus

: The study aimed to develop structured, expert-based clinical guidance on the prenatal and postnatal management of hemolytic disease of the fetus and newborn. A Delphi procedure was conducted among an international panel of experts in fetal medicine, neonatology, and hematology. Experts were selected based on their expertise, relevant publications, and affiliations. The domains were (i) prenatal workup, (ii) prenatal monitoring and management, (iii) intrauterine transfusion, (iv) delivery, and (v) postnatal management. The pre-defined cut-off for consensus was ≥70% agreement. One hundred-seven experts representing 25 countries across six continents completed the first round, and 100 (93.5%) completed the subsequent rounds. 75.3% agreed on using cfDNA to determine fetal antigen status, particularly for RhD, Kell, and Rhc antigens. The critical titer, requiring fetal monitoring via ultrasound, is considered when the threshold of ≥16 is for non-Kell antigens. 70.0% agreed on the use of maternal IVIg in pregnancies with prior intrauterine transfusion (IUT) <24 weeks or fetal/neonatal death due to HDFN. The minimum GA for IUT is 16 to 18 weeks, and the maximum is 350/7 to 356/7 weeks. Postnatal management consensus was reached for the following: anemia labs should be investigated in the affected neonates before hospital discharge (92.0% agreement), and if they received IUT, the labs should be repeated within one week of discharge (84.0% agreement). 96.0% agreed that exchange transfusions should be centralized in hospitals with sufficient exposure and experience, and 92.0% agreed that the hemoglobin cut-off level to consider transfusion following hospital discharge is 7g/dL, and the newborns need to be monitored until 2-3 months of age (96.0% agreement)