Out for Blood: Neonatal Hematology Review - FANNP

FANNP 23RD NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEWPharmacologic Treatment Options…◦ Erythropoetin• Used for treatment of anemia ofprematurity• Dose◦ 500-1400 units/kg/week given single ordivided, SC or IV• Mechanism of Action◦ Colony-stimulating factor◦ Stimulates RBC production and induces therelease of reticulocytes from the bone marrow• Need to be on iron supplement to supportincreased erythropoiesis• Minimize phlebotomy losses and restricttransfusionsPharmacologic Treatment Options…◦ Ferrous Sulfate• Prophylaxis for and/or treatment of anemia ofprematurity• May also be used in older infants with significantanemia• Dose◦ 2-5 mg/kg/day elemental iron given daily with afeeding for total of 4-6 mg/kg/day◦ Iron fortified formula can provide up to 2 mg/kg/day• Mechanism of Action◦ Essential mineral◦ ↑ iron stores• Preterm infants need iron supplement until 12months of age• Overdose (serum > 300 mg/dL)◦ Induce emesis, NaHCO3 lavage and deferoxaminechelationPharmacologic Treatment Options…◦ Heparin Sodium• Uses◦ Anticoagulant typically used for heparin locks and to maintainpatency of central catheters; controversial use for treatment of DIC;during treatment with ECMO; treatment of thrombosis• Dose◦ Heparin Lock 1-2 ml of 10 unit/ml solution every 4-6 hrs and PRN◦ Continuous Infusion for Central Line 0.5-1 unit/ml in infusion fluid◦ Continuous Infusion for Thrombosis dedicated line if possible,initial bolus 75 units/kg followed by continuous infusion 28units/kg/hour, titrate down for lower gestations• Laboratory Monitoring Heparin Activity Level (anti-factor Xalevel) 0.3-0.7 units/ml and/or PTT, CBC to assess forthrombocytopenia• Antidote◦ Termination of therapy◦ Protamine Sulfate IV dose dependent on heparin dose• Mechanism of Action◦ Inhibits the intrinsic clotting cascade and prevents fibrin formation• Precautions◦ Platelet count < 50K, suspected ICH, GI bleeding, shock, severehypotension, uncontrolled bleedingPharmacologic Treatment Options…◦ Enoxaparin (Lovenox)• Low molecular weight heparin• Advantages over standard heparin◦ Predictable pharmacokinetics, decreased need forlaboratory monitoring, subcutaneous dosing,reduced risk of thrombocytopenia, possiblereduced risk of bleeding• Dose◦ 0.5-1.5 mg/kg/dose SQ BID◦ Laboratory Monitoring target anti-factor Xalevel 0.5-1 unit/ml obtained 4-6 hrs afterinjection, CBC to assess for thrombocytopenia• Antidote◦ Termination of injections◦ Protamine Sulfate 1 mg/1 mg LMW heparin givenin last injectionPharmacologic Treatment Options…◦ Tissue Plasminogen Activator (tPA)• Minimal data for safety and efficacy• Agent of choice due to…◦ Allergic reactions associated with streptokinase◦ Availability of urokinase◦ Shortest half-life◦ Less stimulation of systemic prolytic state d/t poor binding ofcirculating plasminogen and maximal impact on fibrin boundplasminogen• Indications◦ Arterial thrombosis, massive thrombosis with evidence of organdysfunction or compromised limb viability, life threatening thrombosis• Dosing◦ 0.1-0.5 mg/kg/hr for 6-12 hrs lysis continues after infusion stops• Laboratory Monitoring/Imaging◦ Prior to Therapy CBC, PT, PTT, fibrinogen; consider evaluation forICH◦ PT, PTT, fibrinogen every 4 hrs initially then every 12-24 hrs◦ CBC every 12-24 hrs◦ Imaging of thrombosis every 6-24 hrs• Management◦ Maintain fibrinogen > 100 mg/dL and platelet count 50K-100KMarathon…a : anendurancecontestb : something(as an event,activity, orsession)characterizedby great lengthor concentratedeffortB14: NEONATAL HEMATOLOGY REVIEW Page 22 of 22