Polycythaemia Neonatal Management Clinical Guideline V1.0

Polycythaemia Neonatal Management Clinical Guideline

V1.0

June 2021

Polycythaemia Neonatal Management Clinical Guideline V1.0 Page 2 of 14

Summary

Infant identified as at risk of

polycythaemia with one sign or symptom

Capillary Haematocrit

identified (Hct) >70%

Venous Full Blood Count sample

Asymptomatic Symptomatic

Venous Hct 75%

Venous Hct 65-70%

Consider Partial Exchange transfusion via UVC/UAC and peripheral venous line Nil by Mouth until Hct < 65% then as per high risk feeding regime Monitor urine output and fluid balance and investigate further causes Regular electrolytes and bilirubin and plot on appropriate chart 6-12 hourly FBC depending on severity of symptoms

Venous Hct >70%

Venous Hct 65-70%

Venous Hct >70%

Capillary Hct identified >65% and

one sign or symptom

Observations 4 hourly for 12 hours. 2 x pre feed blood sugars. Ensure adequate hydration, urine output. Observe for signs of jaundice. Repeat FBC after 12 hours.

Observations 4 hourly for 12 hours 2 x pre feed blood sugars Ensure adequate hydration, increase fluid intake to one day ahead if tolerated. Observing adequate urine output Observe for signs of jaundice

Admit to NNU Neonatal Unit IV dextrose ECG Monitoring High risk feeding regime Fluid balance Monitor electrolytes and bilirubin 12 hourly FBC until asymptomatic and Hct <70%

If worsening symptoms

Symptomatic or worsening FBC

Signs or Symptoms

Hypoglycaemia requiring treatment with IV Dextrose

Jaundice requiring phototherapy

CNS symptoms with unknown cause - Irritability, lethargy, seizure

Poor feed absorption - not tolerating hourly feeds, bilious aspirates

Urine output < 1ml/kg/hr

Infants at risk

Infant of diabetic mother

Prolonged delayed cord clamping >2 mins

Twin to Twin transfusion

Intrauterine growth restriction (IUGR)

Cord pH <7.0

Large for gestational age >98th centile

Chromosomal anomalies such as Trisomy 21, 18 and 13

Severe Preeclampsia

4 hours NEWS observations. Ensure adequate hydration, urine output. Observe for signs of jaundice.


1. Aim/Purpose of this Guideline

1.1. To assist staff with identifying possible causes for, and infants at risk of Neonatal Polycythaemia. This guidance is for the management of these infants in order to prevent further complications.

2. The Guidance

Polycythaemia is defined as a venous packed cell volume/haematocrit (Hct) of over 65%. This condition affects approximately 1-5% of newborns in the postnatal period. Many affected infants are asymptomatic and the characteristic clinical features and related complications are thought to occur as a result of hyperviscosity. It is however important to note that not all polycythaemic infants suffer from hyperviscosity. Hyperviscosity can result in serious clinical consequences due to reduced blood flow to organs leading to poor tissue perfusion and possible microthrombus formation. Sampling variability can occur when measuring haematocrit and therefore a venous, free flowing sample is gold standard and must always be obtained to confirm diagnosis. The treatment of polycythaemia is also variable because it is uncertain whether intervention affects long-term outcome and may be associated with some gastrointestinal morbidity. Dehydration is also a common case of polycythaemia when identified into the 2nd -3rd day of life. This should be corrected and treated accordingly then haematocrit reviewed subsequently. 2.1. Infants at risk of Polycythaemia

Infant of diabetic mother

Delayed Cord clamping with other risk factors

Twin to Twin transfusion

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Intrauterine growth restriction (IUGR)

Intrapartum Hypoxia

Large for gestational age

Chromosomal anomalies such as Trisomy 21, 18 and 13

Maternal Preeclampsia

Endocrine abnormalities such as hypothyroidism, congenital adrenal hyperplasia

2.2. Signs and Symptoms

Many polycythaemic infants will be asymptomatic and only appear plethoric on examination. Polycythaemic infants who are developing hyperviscocity may present with these signs and symptoms over the first 24 hours;

Respiratory distress +/- Apnoea

Cyanosis

Cardiopulmonary complications such as tachycardia, Persistent Pulmonary Hypertension of the Newborn (PPHN), cardiomegaly

Gastrointestinal problems such as poor feeding, vomiting, Necrotising enterocolitis (NEC)

Neurological complications such as lethargy, irritability, jitteriness, seizures

Persistent hypoglycaemia requiring high GIR

Hypocalcaemia

Jaundice requiring more than standard phototherapy

Renal complications such as decreased urine output, renal vein thrombosis

Coagulation difficulties such as thrombocytopenia

2.3. Investigations Haematocrit in term infants, who appear clinically well, should not be measured routinely, including those with risk factors. However, if signs or symptoms occur then the following investigations should be undertaken:

Full maternal and infant history to identify predisposing factors

Systematic clinical examination including: respiratory status, capillary refill time, femorals and bowel sounds


Identify any risk of dehydration such as significant weight loss in first 5 days

In any infant identified to be at risk of polycythaemia and presenting with one of the stated signs or symptoms they must have a venous full blood count (FBC) sent to the laboratory with a full electrolyte sample (green bottle) and blood gas for blood glucose

The diagnosis of polycythaemia can only be made from a venous Hct. It is important to acknowledge that many infants may present with symptoms similar to those attributed to polycythaemia with hyperviscosity and that other aetiologies should also be considered. Symptoms of hyperviscosity are likely to be severe and persistent.

2.4. Management 2.4.1. Asymptomatic and Symptomatic Management

2.4.1.1. Asymptomatic Infants with Hct 65-70%

Clinical polycythaemia management not required

Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required

Observing adequate urine output

Observe for signs of jaundice

2.4.1.2. Asymptomatic Infants with Hct 70-75%

Observations 4 hourly for 12 hours, following flowchart if any symptoms occur

Two pre-feed blood sugars and manage as per Hypoglycaemia guideline if required

Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required

Observe adequate urine output


Repeat venous FBC after 12 hours

2.4.1.3. Symptomatic Infants with Hct 65-70%- see decision making flowchart

Observations 4 hourly for 12 hours, following flowchart if any further symptoms occur


Two pre-feed blood sugars and manage as per Hypoglycaemia guideline if required

Ensure adequate hydration by monitoring oral intake and seeking prompt support from infant feeding team if required. Increase fluid intake to one day ahead, pass nasogastric tube if unable to maintain volumes orally

Observing adequate urine output


2.4.1.4. Symptomatic infants with Hct >70%- see decision making flowchart

Consider admitting to Neonatal Unit and commence IV dextrose for 24 hours minimum (can be fed a day ahead if mild symptoms only- e.g. jaundice only requiring phototherapy, one off hypoglycaemia)

ECG Monitoring

High risk feeding regime

Monitor fluid balance and urine output

Monitor electrolytes and bilirubin and plot on appropriate chart

12 hourly FBC and electrolytes until asymptomatic and HCT <70%

If worsening symptoms such as persistent hypoglycaemia or respiratory distress despite intravenous fluids, to discuss with Neonatal Consultant about performing a partial exchange transfusion

2.4.1.5. Symptomatic or Asymptomatic infants with Hct >75%-

see decision making flowchart

Consider Partial Exchange transfusion via Umbilical Venous Catheter/Umbilical Arterial Catheter and peripheral venous line

Consideration should be given to investigation of other causes of polycythaemia especially if persistent/worsening symptoms

Nil by mouth until Hct < 65% then as per high risk feeding regime


Monitor urine output and fluid balance

Regular electrolytes and bilirubin, and plot on appropriate chart

6-12 hourly FBC depending on severity of symptoms 2.4.2. Partial Exchange Transfusion

2.4.2.1. The accepted treatment of polycythaemia is partial exchange transfusion (PET), however it should be noted that PET has not been shown to have beneficial effects on long term outcomes and due to associated complications should therefore be discussed with the Neonatal Consultant before being undertaken(1). Partial Exchange Transfusion in preterm infants is higher risk and must always be discussed with the Neonatal Consultant; with a cranial ultrasound pre-procedure for all infants <34 weeks CGA.

2.4.2.2. PET involves slowly removing some of the blood volume and replacing the withdrawn blood with fluids to help dilute the red blood cell concentration. Partial exchange transfusion must take place in an intensive care setting with continuous monitoring, following informed parental consent.

2.4.2.3. Vascular access will be required for the transfusion to

take place ideally a UAC/UVC (blood out) and a peripheral venous line (saline in).

2.4.2.4. Volume to be exchanged is 15ml/kg of blood with an at

least 15ml/kg 0.9% Sodium Chloride, this should be performed in 5ml/kg aliquots over 30 minutes (90 minutes total time). Ensure baby’s thermal care is maintained during the procedure (2,3).

2.4.2.5. Equipment

Cardio-respiratory monitoring equipment, including saturation and blood pressure monitoring

Volumetric pump

Sterile gowns, gloves and pack

Closed system urine bag/ paediatric waste urine bag and extension set

Assorted lure lock syringes, 3 way taps and extension sets depending on access

Exchange transfusion observation and in/out chart


Clock

2.4.2.6. Procedure

Use aliquots of 5 mL/kg; withdraw blood and infuse an equal amount of saline

First remove aliquot of blood in volume as above. Always ensure blood is removed first

This first aliquot withdrawn should be sent for FBC, U&E, LFT, phosphate, SBR

Hct, Calcium, magnesium, glucose and clotting

Stop partial exchange transfusion if infant’s condition suddenly deteriorates – but always

Leave infant’s blood volume in balance

Sudden deterioration maybe be due to underlying condition, the procedure or an adverse reaction to transfusion

Blood glucose should be measured prior to and after procedure

2.4.2.7. Complications of PET

Gastrointestinal disturbances (e.g. abdominal distention, vomiting)

Necrotising enterocolitis

Electrolyte disturbances e.g. Hypoglycaemia

Infection

2.4.2.8. Procedure: Nursing roles and Responsibilities

Do not interrupt the phototherapy during exchange.

Ensure parents are fully informed and have consented to procedure

Ensure baby is in the Intensive care room and begin monitoring heart rate, respirations, blood pressure, oxygen saturations and temperature. Record baseline observations prior to procedure and then every 15 mins throughout the exchange

Maintain neutral thermal environment, ideally in open cot


Baby must be nil by mouth prior to an exchange, leave NGT on free drainage

Administer IV fluids as prescribed and observe all lines as per policy

Record pre transfusion blood glucose and then following the procedure

Ensure day 0 blood spot sample has been taken and labelled

Use a chart to document in and out volumes

All clinical staff should be ready to start simultaneously and should have no other workload ie 1:1 care

All lines should be monitored for extravasation, blanching, erythema, leakage, and oedema. They should be recorded as per Trust policy

On completion the lines should be flushed with saline to maintain patency

Inform parents that procedure has been completed

Documentation - contemporaneously documented, accurate fluid balances, sample taken, observations, and any untoward reactions and outcomes reported appropriately

2.4.2.9. Nursing care post procedure

Monitor and record blood glucoses at 1,2 and 4 hours post transfusion

Observe for any distension, vomiting, and blood in stools

Urinalysis

Repeat FBC 6 hours post PET


3. Monitoring compliance and effectiveness

Element to be monitored

Compliance with policy/ key changes to practice

Lead Neonatal Guidelines Lead and Author

Tool Adherence to guidelines will be monitored as part of the ongoing audit process on a Word or Excel template

Frequency As dictated by audit findings

Reporting arrangements

Neonatal Guidelines Group

Acting on recommendations and Lead(s)

Neonatal Guidelines Lead and Author

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 3 months, immediately if required. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant staff/stakeholders

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Polycythaemia Neonatal Management Clinical Guideline V1.0

This document replaces (exact title of previous version):

New Document

Date Issued/Approved: January 2021

Date Valid From: June 2021

Date Valid To: June 2024

Directorate / Department responsible (author/owner):

Jenna Julian; Neonatal Nurse

Contact details: 01872 252667

Brief summary of contents Guideline on the management of neonates with suspected or confirmed polycythaemia

Suggested Keywords: Neonatal Polycythaemia, Exchange Transfusion

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:


General Manager confirming approval processes

Mary Baulch

Name of Governance Lead confirming approval by specialty and care group management meetings

Caroline Amukusana

Links to key external standards None Required

Related Documents:

1. Dempsey, E. M., Barrington, K. (2006) Short and long term outcomes following partial exchange transfusion in the polycythaemic newborn: a systematic review. Arch Dis Child Fetal Neonatal Ed. 91(1).

2. Ghoshal, S., Matthews, Y. Y. (2011) Polycythaemia and Hyperviscosity in Newborn.

3. ADHD (2012) Newborn Clinical services guideline- Partial Exchange Transfusion.

4. Garcia- Prat, J.A. (2019) Neonatal Polycythemia.

Training Need Identified? No

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

http://www.wales.nhs.uk/sitesplus/documents/1002/Polycythemia%202011.pdf

http://www.wales.nhs.uk/sitesplus/documents/1002/Polycythemia%202011.pdf

http://www.adhb.govt.nz/newborn/guidelines/blood/exchange/PartialExchange.htm

http://www.adhb.govt.nz/newborn/guidelines/blood/exchange/PartialExchange.htm

https://www.uptodate.com/contents/neonatal-polycythemia?search=neonatal%20polycythemia&source=search_result&selectedTitle=1~13&usage_type=default&display_rank=1#H18


Document Library Folder/Sub Folder

Clinical/ Neonatal

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job

Title) January 2021

V1.0 Initial issue Jenna Julian; Neonatal Nurse

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2. Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Polycythaemia Neonatal Management Clinical Guideline V1.0

Directorate and service area: Neonatal

Is this a new or existing Policy? New

Name of individual/group completing EIA Neonatal Guidelines Group

Contact details: 01872 252667

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

Medical and Nursing staff caring for Neonates within Maternity and Neonates

2. Policy Objectives Provide a framework for assessment and management of infants with symptomatic and asymptomatic polycythaemia.

3. Policy Intended Outcomes

To improve the well-being of patients by offering the appropriate management.

4. How will you measure the outcome?

Audit/ Multidisciplinary team weekly discussion/ incidents/ risk management

5. Who is intended to benefit from the policy?

Patients and their families.

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Please record specific names of groups:


c). What was the outcome of the consultation?

Approved- 20th January 2021


7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male, female non-binary, asexual etc.)

X

Gender reassignment X

Race/ethnic communities /groups X

Any information provided should be in an accessible format for the parent/carer needs – i.e. available in different languages if required/access

to an interpreter if required

Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)

X

Those parent/carers with any identified additional needs will be referred for additional support as

appropriate- i.e. to the Liaison team or for specialised equipment.

Written information will be provided in a format to meet the family’s needs e.g. easy read, audio etc

Religion/ other beliefs X

All staff should be aware of any beliefs that may impact on the decision to treat

Marriage and civil partnership X

Pregnancy and maternity X

Sexual orientation (bisexual, gay,

heterosexual, lesbian) X

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:


If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docx

mailto:[email protected]