Indian J Pediat 49 : 519-523, 1982

A comparative study on the value of exchange and blood transfusion in the management of severe neonatal septicemia with sclerema Indira Narayanan, M.D., A. Mitter, M.D., and V.V. Gujral, M.D.

This study comprised of 60 neonates with severe septicemia with sclerem a. The infants were divided into three groups of 20 each. All of them received conventional treatment including antibiotics and steroids. Infants in groups II, in addition were given a simple transfusion (whole blood 20 ml]kg), and those in group HI an exchange transfusion (160-190 ml/kg of fresh blood). Morbidity and mortality was significantly less in children who were given exchange transfusion in addition to the conventional treatment ( p/__0.05 ). Key words : Septicemia, exchange transfusion.

Despite improved obstetric and pediatric care, septicemia still contributes greatly to neonatal morbidity and mortality, particularly in developing countries. Clinical profile is severe as evidenced by the presence of sclerema neonatorum and other features. Mortality even in advanced centres is very high. 2A There are a few reports in the world literature regarding the beneficial effects of exchange transfusion in severe neonatal septicemia. 3"4'we No reports are available from India where From the Kalawati Saran Children's Hospital, Lady Hardinge Medical College, New Delhi. Reprint requesls to : Dr. lndira Narayanan, Lecturer.

this problem is of a greater magnitude than in advanced countries.

Material and Methods 60 infants under the age offour weeks, admitted at the Kalawati Saran Childrert's Hospital were included in this study. A diagnosis of severe neonatal septicemia was made arbitrarily only when, in addition to at least one positive blood culture and sclerema, six or more of the following features were present; namely, lethargy, facial grimace, fever / hypothermia, abdominal distension, intestinal stasis, diarrhea, regurgitation, and respiratory distress. Infants with features such as apnoeie spells and obvious neurological

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deficits indicative of central nervous system involvement and neonates with meningitis were not included. Investigations including blood counts, E.S.R., serum electrolytes, blood urea and sugar were carried out. The general and nursing care were similar for all the infants. All the neonates were treated with gentamycin (5-7.5 nag /kg/24 hours) and cloxacillin (100 mg/kg 124hours). Subsequently appropriate changes were made where necessary in accordance with the sensitivity pattern o f the organism in individual cases. The management differed only in the following respects; Group 1 :- (20 infants)-steroids (dexamethasone- 0.4 mg/kg.). G r o u p / / : - (20 infants)-,steroids and fresh whole blood transfusion - (20 ml./kg.). Group 111 :- ( 20 infants ) - steroids and exchange transfusion with fresh blood(160 - 190 ml./kg.).

Table I Distribution and outcome according to sex, birth weight and estimated gestatioual age

Results

The distribution o f the sex, birth weight and estimated period ofgestational age are indicated in Table I. There were no statistically significant differences in the three groups. The groups were also matched for the socioeconomic and educational status of the parents, both being uniformly poor in all the cases. There were also no significant differences in the factors predisposing to the occurrence o f infection and in the age o f onset o f the symptoms (Table II). The place of delivery and the reasons for admission to the hospital were similar in the three groups. The majority of the neonates had been delivered in the hospital and wereadmitt-

Feature

Total Number

Group I Group II Group IlI 20(12) p>0.05

20(18)

20(14)

12(11) 8(7)

13(11) 7(3)

10(6) 10(6)

6(6) 8(8) 4(4) 2(0)

5(5) 9(6) 4(2) 2(1)

7(6) 7(4) 3(2) 3(0)

2(2) 13(13) 5(3)

2(2) 10(8) 8(4)

2(1) 10(8) 8(3)

Sex

Males Females Birth weight

1001--1500 gm. 1501--2000 gm. 2001--2500 gm. 2501--3000 gin. Gestational Age

28--32 weeks 33--36 weeks 37--41 weeks

(Note :--Deaths indicated in parenthesis) Table II Distribution of predisposing factors and age at onset of symptoms Feature

Group I Group II Group HI

A. Predisposing'Factors

1. Prolonged rupture of membranes (>24 hours) 2 2. Maternal infection 4 3. Vaginal examination by 'dais' 4. Birth asphyxia

2 5

B. Age at onset of symptoms

1. 1--3 days 2. 4---7days 3. 8--14 days 4. 15--28 days

5 9 4 2

4 8 5 3

2 6

NARAYANAN ET AL" EXCHANGE"I'RANSFUSIONVS. BLOODTRANSFUSION IN SEPrlCEMIA 521 ed into the neonatal specialcare unit for prematurity and/or low birth weight per se

Exchange transfusion was performed through the umbilical route. 8 infants were between 4-7 days at the time of the procedures, 9 were between 8-14 days, 2 The organisms isolated from the blood between 15-21 days and one was 28 days are shown in Table Ill. G r a m negative old. In some of the older neonates a supra bacilli, notably E. coli, Klebslella, and umbilical venesect~on was carried out for Pseudomonas were the common isolates. introduction o f the cannula. There were no significant differences in Mortality was significantly less in group the total number of G r a m negative bacilli I l I in which exchange transfusion was and G r a m positive cocci in the groups. carried (Table I, p < 0 05). There were also There were no significant differences more survivors in group I l l as compared between the three groups in the results of to with group lI in which the babies were the investigations such as blood counts, administered simple blood transfusions E.S.R., serum electrolytes, blood urea, but this difference was not statistically etc. significant. Among the 12 deaths in group III, Table lII. Organisms isolated in the Blood there were three cases o f nccrotising enteTocolitis with typical clinical and Organism Group I Group II Group llI radiological features. Another infant who was improving and whose repeat blood culture was sterile died of aspiration of A. Gram-re bacilli15(11) his vomitus. There were no cases of necroTotal 15(15) 17(13) p<0.05 rising cntcrocolitis in groups I and II. As far as birth weight and gestational 4 E. coil 3 5 age were concerned, the numbers were 3 Klebsiella 5 3 too small for statistical evaluation but it 4 Pscudomonas 3 3 is clear f r o m Table I that in group I, only Salmonella newterm infants above 2500 gm, recovered, in 2 port 2 -groups II and Ill, there were survivors Scrratia marces1 cens 1 3 even in the preterm and low weight 1 Mixed 1 3 categories. Again, in relation to the causative organisms, it was observed that in B. Gram+re cocci/coccobacilli group I, survivors were only in cases with Total number 5(3) 3(1) 5(i) infection with G r a m positive cocci (Staph. pyogenes), which in any case have a better Staph. pyogenes 3 3 4 p r o g n o s i s : On the other hand, there was Haemolytic streptoi an improvement in groups II and III, cocci --Mima polymorpha 1 -especially the latter, not only in these Strept. faecalis 1 -cases, but also, more significantly, (p <0.05) in those due to G r a m negative (Note :--Deaths indicated in parenthesis) bacilli, (Table IIl).

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Problems encountered in carrying out the exchange transfusion included reluctance on the part of the relations to donate blood.

Discussion Reports in India on the outcome of neonatal septicemia pertain to the total spectrum and not only to severe cases with sclerema rT. In some more advanced centres, the mortality has ranged between 75-1004's. In 1991, Davies9 advocated transfusion of fresh blood not only for correcting associated anemia, but also for providing polymorphonuclear leucocytes and serum opsonins. In the present series too, there was some decrease in the mortality in the group ( lI ) receiving blood transfusion, although this was not statistically significant. The value of exchange transfusion was first reported by Torrado 3. Subsequently a few other studies have also shown beneficial results. 4'5'6 In our study, too, there was a significant improvement in the outcome in the infants who underwent exchange transfusion. As far as the route for the exchange transfusion is concerned, we have found the umbilical route is better. Umbilical vein is more easily accessible and permits a freer flow of blood. Regarding the problem of neerotising enterocolitis, it is one of the recognised complications of an exchange transfusion. 10 We feel, however, that it is mainly a feature in a sick compromised infant, as it was not observed in healthy infants on whom the indication was only hyperbilirubinaemia.

Vol. 49, No. 399

One of the interesting features was the significant improvement in the general condition after the exchange transfusion. The beneficial effect has been related to several mechanisms. It has been suggested that the procedure may correct metabolic disturbances such as acidosis, control circulatory shock, remove bacteria and endotoxins, increase phagocytic activity, and improve humoral and cellular defence mechanism. 4'6 It has also been shown to have some value in the management of some eases of disseminated intravascular coagulation, ta Recent studies have also suggested that it increases the opsonic function.aZ'13 Subsequent to the above study, we have been evaluating the benefits of multiple simple and exchange transfusions. We have, in addition, substituted hydrocortisone for dexamethasone on the presumption that it will better counteract any associated endotoxic shock, a4 We have further instituted the practice of administering oral gentamycin (5-7.5mg./kg.) prior to performing the exchange transfusion and have recently also commenced it on a prophylactic basis on all sick infected preterm infants.15 Preliminary results suggest an improved outcome with multiple simple and exchange transfusions, particularly the latter, and, since the introduction of oral antibiotic, we have so far not had any proved cases of necrotising enterocolitis in the analysed cases. In conclusion, we feel that exchange transfusion, wiih fresh blood improves the chances of survival in neonates with severe septicemia.

Acknowledgemen t The authors are grateful to Mr. P.

NARAYANAN ET AL: EXCHANGE TRANSFUSION VS BLOOD TRANSFUSION IN SI'P]ICI2MIA

Kumar and Mr. R.K. Verma for aid in statistical evaluation and to Dr. S. Chawla. Principal, Lady Hardinge Medical College, New Delhi, for granting ~ermission to publish this paper.

6.

Tollner U. Pohlandt F, Heinze F, Henricks I: Treatment of septicaemia in the newborn infants: Choice of initial anti-microbial drugs and the role of exchange transfusion, Acta Pediatr Scand 66: 605, 1977

7.

Gupta S, Chopra K, Pramanick A : Perina~al and neonatal morbidity and mortality in the hospital born babies. Ind Pediatr 9: 586, 1972

8.

Hughes WE, Hammond M L : Sclerema neonatorum. J Pediatr 32 : 676. 1948

9.

Davies P : Bacteria/infection in the foetus and newborn Arch Dis Child 46: 1, 1971

I0.

Ananda JV, Sweet AY: Alterations in blood pressure during exchange transfusion. Arch Dis Child 52 : 545, 1977

II.

GrossS, Melborn D K : Exchange transfusion with citrated whole blood for disseminated intravascular coagulation. Pediatr. 78: 415, 1971

12.

Pelet B : Exchange transfusion in newborn infants: effects on granulocytic function. Arch Dis Child 54 : 687, 1979

13.

Larcher V, Mowat AP: Exchange transfusion in newborn infants. Arch Dis Child 55 : 322, 19~0

14.

Dierzman R H : Therapeutic effects of corticosteroids in septic sdock. Acta Chir Belg 72 9 308, 1973

15.

Grylack LJ, Scanlon JW: Oral gentamycin therapy in the prevention of neonatal necrotising enterocolitis: a controlled double blind trial. Am J Dis Child 132: 1192, 1978

References

1.

Bhakoo, ON : Prognosis and .treatment of neonatal septicaemia-a clinico-bacteriogical study of 100 cases. Ind Pc~iatar 11:519, 1974

2.

Levine SE, Bakst CM, Isserow L.: Sclerema neonatorum treated with corticostero.d. Br MedJ 2: 1533, 1961

3.

TorredoA, Mazouni M, Prod:'him LS: L' exsanguinotransfusion comme moyen theraapeutique dons les sepsis neonatales compliques de sclereme. Soc Suisse Ped., Congres de Geneve, 15-17, Juin, 1973

4.

5.

Prod'horn LS, Choffat JM, Frenck N, Mazouni M, Relier JP, Torrado A: Care of the seriously ill neonate with hyaline membrane disease and with sepsis (sclerema neonatorum). Pediatr 53 : 170, 1974 Prod'hom LS, Lemos L., Mazouni M, Torrado A : Exchange transfusion of fresh whole blood as treatment of severe neonatal septicaemia associated with sclerema. Current Topics in Pediatrics. Proceedings of the XV International Congress of Pediatrics 1806/12, p. 12, 1977

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