The Use of Placental Blood on Admission to the NICU
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Background: Upon admission to the Neonatal Intensive Care Unit (NICU), very low birth weight (VLBW) infants are routinely phlebotomized within the first hours of life. Though necessary, this can lead to poor outcomes including anemia, early red blood cell transfusion within the first two weeks of life, intraventricular hemorrhage (IVH), and pain. It is not a common process for blood to be drawn on admission from the placenta. However, a few studies have demonstrated that use of placental blood for initial labs is sustainable in a clinical setting even with placental abruption or delayed cord clamping and results in higher hematocrits and a reduction in blood transfusions over the first week of life for VLBW infants. Purpose: The purpose of this project was to implement and assess the feasibility of drawing initial laboratory specimens for all infants upon admission to the NICU from the otherwise discarded placenta, eliminating the need for heel lance, venous sticks, and arterial draws. Methods: NICU RNs were trained to draw blood culture and complete blood count (CBC) laboratory specimens from the placenta in the delivery room prior to NICU admission. Prenatal assessment and clinical status of each infant determined what specimens, if any, would be drawn on admission. Though this change was implemented for all infants admitted to the NICU, the population for this evaluation were VLBW infants whose mother did not have a placental abruption, and for which RNs could draw at least some blood for admission laboratory specimens from the placenta. A medical chart review was conducted on data from pre- and post-implementation infants to compare hematocrit levels, frequency and timing of blood transfusions in the first week of life, and the overall incidence of IVH. Results: Twenty infants were evaluated pre-implementation and twelve infants underwent the placental blood draws post-implementation, with only eight meeting all the inclusion criteria. The mean gestational age in both pre- and post- implementation groups was 28 weeks, and the mean birthweight was 1122.5 grams and 987.5 grams respectively. Of the infants who had hematocrits drawn on day of life (DOL)1, the pre-implementation group (N=7) had an average hematocrit of 45%, and the post-implementation group (N=6) had an average hematocrit of 46.5%. There was a delay in the administration of the first blood transfusion in the post-implementation group (N=2, mean= DOL 4) versus the pre-implementation group (N=2, mean= DOL 0.5). There was also less significant IVH in the post-implementation group (N= 1, Grade 1 IVH) versus the pre-implementation group (N=2, Grade 3-4 IVH). The placental draw procedure was found to be feasible and sustainable in the clinical setting. The success rate for drawing admission laboratory specimens for all twelve infants post-implementation was 56% for CBCs and 75% for blood cultures. There were no contaminated blood culture specimens. Implications for practice and research: Literature review suggests that drawing laboratory specimens from the placenta is becoming a common practice in some areas of the country. In addition to blood cultures and CBCs, cord or placental blood has been used for blood typing, antibody screening, microarray, karyotyping, and other laboratory tests. The state of Nebraska is evaluating the use of placental blood for metabolic screening. Development of RN expertise in the technique for drawing blood from the placenta is essential to the success of this practice. With this new practice change, we will continue to evaluate the process and infant outcomes.