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Brief Reports Indian Pediatrics 2002; 39:657-659 |
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Exchange Blood Transfusion in Neonatal Hyperbilirubinemia-Role of Calcium |
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K.K. Locham
Neonatal jaundice is seen in approximately 80% of preterm and 60% of term babies(1). Whole blood collected in citrate phosphate dextrose (CPD) is preferred for doing exchange, but citrate in CPD binds calcium leading to formation of unionized calcium compound. After injection, the citrate ion is removed from blood within few minutes by the liver and is polymerized into glucose or metabolized directly for energy(2). Administration of calcium gluconate has been reported to interfere with rate of citrate removal from the blood(3). The role of giving extra calcium during exchange transfusion is not clear. The present study was designed to evaluate the need for giving extra calcium during exchange transfusion or not. Subjects and Methods The study was conducted on 30 healthy appropriate for gestational age (AGA) babies with neonatal jaundice, requiring exchange blood transfusion as per Cashore and Stern chart(4) and as per recommended indications(5). Patients were allocated alternatively to two groups; namely study group and control group. No specific randomization and blinding was done. Fifteen cases of study group were administered 1ml of 10% calcium gluconate IV for every 100 ml of CPD blood exchanged, while 15 cases of control group were not administered calcium. Double volume exchange was done in thermoneutral environment using fresh blood containing CPD as anticoagulant. Cardiac monitoring was done during the procedure. Estimation of total and ionized serum calcium and total and differential serum bilirubin were done immediately before the start and after the completion of exchange transfusion. Serum bilirubin was estimated by method of Malloy and Evelyn(6). Total serum calcium level was estimated by Trinder’s method(7). Ionic calcium was calculated by Zeisler’s method(8). Results The mean total serum calcium levels pre and post exchange were 9.57 ± 0.34 mg/dl and 9.76 ± 0.34 mg/dl respectively in the study group. The rise in total calcium levels (post exchange) was significant (p<0.01). In control group, the mean total serum calcium levels, pre and post exchange were 10.12 ± 0.60 mg/dl and 9.85 ± 0.54 mg/dl respectively. There was fall in total serum calcium levels after exchange and this fall was highly significant (p<0.01). In study group, mean ionized serum calcium levels pre and post exchange were 4.77 ± 0.15 mg/dl and 4.82 ± 0.17 mg/dl, respectively. The rise in ionized calcium levels (post exchange) was significant (p<0.05), whereas in control group there was fall in ionized serum calcium levels (pre exchange = 4.91 ± 0.13 mg/dl and post exchange = 4.74 ± 0.15 mg/dl) which was significant (p<0.001). There was no documented hypocalcemia in either study or control group. Apnea, hypoglycemia and death was seen in one patient each in study and control groups. However, cardiac arrest was observed in one case of study group only. Discussion In present study, although a significant fall in total and ionized calcium levels were observed in the control group after exchange transfusion, these did not result in hypo-calcemia. In the study group, there was a rise in total and ionized serum calcium (post exchange), but hypercalcemia was not documented, similar to earlier observations(9). Extremely low calcium levels during exchange transfusion have been observed in some studies(9, 10). Hypocalcemia as a complication has also been reported(11), but it was not observed in our study. The rise in calcium level in study group may be due to exogenously administered calcium. Bradycardia and wide fluctuations in heart rate are reported following the injections of calcium gluconate(12,13). One neonate in our study group had cardiac arrest. Hypoglycemia, apnea and death were comparable in both the groups. Adminis-tration of calcium gluconate has been reported to interfere with rate of citrate removal from blood(3). It is concluded that administration of calcium is not required during exchange transfusion. However as the sample size was small and no specific randomization and blinding was done in our study, a larger study is required to confirm our findings. Contributors: KKL supervized data collection and drafting the manuscript; he will act as the gurantor of the paper. RT and KK collected the data and helped in analysis. MK and RG helped in drafting the paper. Funding: None. Competing interests: None stated.
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