To study the outcome of exchange transfusion in severe neonatal sepsis in neonates admitted in NICU at

Background: Sepsis is one of the most common causes of neonatal mortality and morbidity. Immaturity of the immune system, newborn infants are highly susceptible to systemic infection. Blood exchange transfusion in severe neonatal sepsis remove bacteria, bacterial toxins, and circulating pro-inflammatory cytokines, improve perfusion and tissue oxygenation, correct the plasma coagulation system and enhance immunological defence mechanisms. Material and methods: This is a hospital-based, time-bound, analytical observational study conducted from January 2019 to December 2019 in the NICU of Dr. B.R.A.M. Hospital & Pt. J. N. M. Medical College, Raipur, Chhattisgarh, India. The data was collected in pre-designed proforma, entered in Microsoft Excel and analysis was done using SSPS v 22.0. Result: About 42 neonates were diagnosed with severe neonatal severe. Of which 23 (54.76%) were preterm, 42.24% were term neonates. Maximum 22 (52.38%) were VLBW, 4.76% were LBW and 19.05% were with normal birth weight. In the study two-third of 28 (66.67%) were outborn and one third were inborn. In the present study majority of 30 (71.43%) had EOS and 12 (28.57%) had LOS. In our study out of 42 study subjects 24 (57.14%) died and 18 (42.86%) were discharged after blood exchange transfusion. Of those who died 15 (62.5%) were preterm and of those discharged 10 (55.6%) were term neonates (p=0.349). Outborn neonates more died as compare to inborn though this was also not significant (p=0.133). Conclusion: significant reduction of mortality in patients who underwent exchange transfusion, together with the no adverse effects observed, suggest that this procedure should be considered for the treatment of neonates with severe sepsis.


Introduction
As per World Health Organization (WHO) sepsis/infection is one of the most common causes of neonatal mortality and morbidity [1]. It has been estimated that 7.6million children younger than five years of age died in 2010; of these deaths, 64% were attributed to infectious causes, and neonates contributed to a significant proportion (40.3%) [2].
Owing to the immaturity of the immune system, The mortality rate can reach 60% in very low birth weight infants (VLBWI, birth weight < 1500 g) [7].
Early diagnosis, timely administration of appropriate antibiotics, and proper supportive therapy are crucial to improve survival and reduce long-term sequelae [8,9]. Unfortunately, neonatal sepsis can progress rapidly to septic shock, occurring in 1.3% of neonates hospitalized in a neonatal intensive care unit (NICU), with an overall mortality of 40%, reaching 71% in neonates weighing less than 1000 g at the onset of sepsis [10].
Case reports published in the medical literature in the 1970s [11,12]. reporting the effective use of exchange transfusion (ET) in severe neonatal infection with sclerema prompted some authors to use this procedure as rescue therapy in neonates with severe sepsis in subsequent years [13][14][15].
The rationale for the use of ET using fresh, whole, adult blood is to remove bacteria, bacterial toxins, and circulating pro-inflammatory cytokines; to improve perfusion and tissue oxygenation; to correct the plasma coagulation system; and to enhance immunological defence mechanisms (increase in circulating levels of C3, immunoglobulins, improvement in the opsonic activity against the pathogen, enhancement of neutrophil function) [16][17][18].
Despite these potential benefits, very few studies were conducted in the last few decades to investigate the clinical efficacy of ET in neonatal sepsis and septic shock [16,[19][20]. Although most studies showed some beneficial effects to the use of ET, clear evidence for its clinical efficacy is lacking.
The discrepancy observed across studies can be attributed largely to the use of different inclusion and exclusion criteria, diagnostic criteria, and study designs.
However there is a paucity of published studies and data on exchange transfusion on the outcome of neonatal sepsis cases particularly in developing countries. Therefore this prospective study was decided to conduct in a tertiary care teaching hospital in central India to measure the outcome of exchange transfusion in severe neonatal sepsis in term and preterm neonates.

Results
In our study around half of the study subjects were 23 (54.76%) were preterm and the rest were term neonates. In the study two-third of 28 (66.67%) were outborn and one third were inborn admissions who underwent exchange transfusion.        were discharged after treatment.    Table 6 shows the association b/w hospital stay and treatment outcome of study subjects Association was tested using the chi-square test and it was statistically significant (p=0.000).

Conclusion
The study showed that in study subjects who underwent exchange transfusion 57.14% died and 42.86% were discharged after exchange transfusion treatment. Of those who died around two-third were preterm also, outborn neonates more died as compare to inborn though this was also not significant. Before exchange transfusion all the newborns had sclerema and that improved in 55% cases after exchange transfusion.
In the study 76.19% had cardiovascular dysfunction, 66.67% had respiratory system dysfunction and 26.19% had renal system dysfunction. On vitals except for blood pressure (p=0.000) none of the vitals i.e. temperature, PR, Spo2, Random blood sugar had a significant mean difference in their mean value before and after exchange transfusion. Neonates who stayed for a fewer number of days in hospitals had more dying as compared to those who stayed for longer duration and this was also statistically significant.
In conclusion, a significant reduction of mortality in patients who underwent exchange transfusion, together with the no adverse effects observed, suggest that this procedure should be considered for the treatment of neonates with severe sepsis. Thus, it is a safe procedure in severely septic neonates with inherent potential for complications. One needs to exercise caution in selecting the neonate and the team, and take all the necessary precautions irrespective of the indication. The exchange transfusion must be performed only by experienced individuals at a perinatal-neonatal centre using both a cardio-respiratory monitor and pulse oximeter. The team should be ready to respond to any adverse event that may arise at any stage of the procedure.