Neonatal Transfusion Practices Research Articles

Red Blood Cell Transfusion in European Neonatal Intensive Care Units, 2022 to 2023

Red blood cell (RBC) transfusions are frequently administered to preterm infants born before 32 weeks of gestation in the neonatal intensive care unit (NICU). Two randomized clinical trials (Effects of Transfusion Thresholds on Neurocognitive Outcomes of Extremely Low-Birth-Weight Infants [ETTNO] and Transfusion of Prematures [TOP]) found that liberal RBC transfusion thresholds are nonsuperior to restrictive thresholds, but the extent to which these results have been integrated into clinical practice since publication in 2020 is unknown. To describe neonatal RBC transfusion practice in Europe. This international prospective observational cohort study collected data between September 1, 2022, and August 31, 2023, with a 6-week observation period per center, from 64 NICUs in 22 European countries. Participants included 1143 preterm infants born before 32 weeks of gestation. Admission to the NICU. Study outcome measures included RBC transfusion prevalence rates, cumulative incidence, indications, pretransfusion hemoglobin (Hb) levels, volumes, and transfusion rates, Hb increment, and adverse effects of RBC transfusion. A total of 1143 preterm infants were included (641 male [56.1%]; median gestational age at birth, 28 weeks plus 2 days [IQR, 26 weeks plus 2 days to 30 weeks plus 2 days]; median birth weight, 1030 [IQR, 780-1350] g), of whom 396 received 1 or more RBC transfusions, totaling 903 transfusions. Overall RBC transfusion prevalence rate during postnatal days 1 to 28 was 3.4 transfusion days per 100 admission days, with considerable variation across countries, only partly explained by patient mix. By day 28, 36.5% (95% CI, 31.6%-41.5%) of infants had received at least 1 transfusion. Most transfusions were given based on a defined Hb threshold (748 [82.8%]). Hemoglobin levels before transfusions indicated for threshold were below the restrictive thresholds set by ETTNO in 324 of 729 transfusions (44.4%) and TOP in 265 of 729 (36.4%). Conversely, they were between restrictive and liberal thresholds in 352 (48.3%) and 409 (56.1%) transfusions, respectively, and above liberal thresholds in 53 (7.3%) and 55 (7.5%) transfusions, respectively. Most transfusions given based on threshold had volumes of 15 mL/kg (470 of 738 [63.7%]) and were administered over 3 hours (400 of 738 [54.2%]), but there was substantial variation in dose and duration. In this cohort study of very preterm infants, most transfusions indicated for threshold were given for pretransfusion Hb levels above restrictive transfusion thresholds evaluated in recent trials. These results underline the need to optimize practices and for implementation research to support uptake of evidence.

Platelet transfusion practices among neonatologists in Saudi Arabia: A nationwide cross-sectional survey.

The etiologies of thrombocytopenia are highly diverse; however, early neonatal thrombocytopenia might be more common among extremely low-weight neonates. Therefore, in this study, we aimed to examine the current neonatal platelet (PLT) transfusion practices in Saudi Arabia. This is a cross-sectional online survey study that was conducted between October and December 2022. Convenience sampling was used to recruit the participants. In this study, we developed a questionnaire based on an extensive literature review to examine current neonatal PLT transfusion practices. A total of 81 neonatologists participated. The vast majority of them (85.2%) were practicing in a level 3 neonatal intensive care unit, with 60.0% of them reporting that they transfuse PLTs over 1 hour. Around 53% reported that they typically order 10 mL/kg per PLT transfusion. Up to 34.6% of the study participants reported that they use pooled whole-blood-derived PLT products in their practicing unit. Almost half (48.0%) of the study participants reported that they have written guidelines for PLT transfusion in their practicing unit, with 81.1% reporting that the PLT transfusion threshold was stated in the guidelines. Neonatal thrombocytopenia is typically treated with PLT transfusions. PLT transfusion criteria should be lowered in light of recent evidence suggesting that doing so may be counterproductive. However, there is some disagreement about whether a PLT count constitutes a medical emergency requiring a transfusion for a newborn baby. Furthermore, there is a great deal of variation in the administration of PLT infusions in Saudi Arabia because of the absence of clear protocols. Strict neonatal PLT transfusion standards and carefully planned clinical research are needed to address the risks and/or benefits of these diverse methods.

Survey of transfusion practices in preterm infants in Europe

BackgroundPreterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in...

Transfusion therapy of neonatal and paediatric patients: They are not just little adults.

Patient blood management (PBM) strategies are needed in the neonate and paediatric population, given that haemoglobin thresholds used are often higher than recommended by evidence, with exposure of children to potential complications without meaningful benefit. A literature review was performed on the following topics: evidence-based transfusions of blood components and pharmaceutical agents. Other topics reviewed included perioperative coagulation assessment and perioperative PBM. The Transfusion and Anaemia Expertise Initiative (TAXI) consortium published a consensus statement addressing haemoglobin (Hb) transfusion threshold in multiple subsets of patients. A multicentre trial (PlaNeT-2) reported a higher risk of bleeding and death or serious new bleeding among infants who received platelet transfusion at a higher (50 000/μl) compared to a lower (25 000/μl) threshold. Recent data support the use of a restrictive transfusion threshold of 25 000/μl for prophylactic platelet transfusions in preterm neonates. The TAXI-CAB consortium mentioned that in critically ill paediatric patients undergoing invasive procedures outside of the operating room, platelet transfusion might be considered when the platelet count is less than or equal to 20 000/μl and there is no benefit of platelet transfusion when the platelet count is more than 50 000/μl. There are limited controlled studies in paediatric and neonatal population regarding plasma transfusion. Blood conservation strategies to minimise allogenic blood exposure are essential to positive patient outcomes neonatal and paediatric transfusion practices have changed significantly in recent years since randomised controlled trials were published to guide practice. Additional studies are needed in order to provide practice change recommendations.

Neonatal and pediatric transfusion practices and policies in India: A survey-based cross-sectional assessment of blood centers.

Blood centers play a critical role in supporting neonatal and pediatric transfusions. We aim to study the variation in pediatric/neonatal transfusion policies and practices for blood centers in India. This is a survey-based (45 question) cross-sectional assessment of blood centers in India supporting pediatric/neonatal transfusions. One hundred three centers responded to the survey (response rate 51.2%; 103/201). As a part of pretransfusion testing, use of "microtainers" was reported by 58.4% (59/101) centers and only 57.4% (58/101) centers provide antibody screening. In case of absence of maternal sample, type O negative blood is most commonly used (48.5%; 49/101), and in case of ABO incompatibility, 68.3% (69/101) use units compatible with both mother and newborn. Leukoreduced RBCs are provided by 89% (90/101) centers and irradiated products are provided by 48.5% (49/101). 82% (83/101) of centers reported not receiving requests for CMV negative units considering the high incidence of CMV-seropositivity in donors. Fresh units are defined as <7 days old by 44.5% (45/101) and <5 days old by 31.6% (32/101) centers. 97% centers reported SAGM suspended RBCs in inventory but only 67.3% (68/101) use them for top-up transfusions to neonates. Overall >80% centers use the buffy-coat method for platelet concentrates preparation. Volume-based (ml/kg) aliquots preparation is done by 88% (89/101), mainly using the sterile connecting device (84.6%; 83/98). This survey shows heterogeneity and lack of standardization in practices across blood centers in India and highlights the need for more studies to establish best practices for this vulnerable age group.

Neonatal Transfusion Practice: Hemolysis Markers After In Vitro Infusion of Packed Red Blood Cells by the Gravitational Method or Syringe Pump in a Peripheral Catheter.

The objective of this study was to verify the influence of the gravitational infusion method or syringe infusion pump on changes in hemolysis markers of irradiated and nonirradiated packed red blood cells (PRBCs) in vitro administered in a neonate peripheral intravenous catheter. An experimental study was conducted in a laboratory under controlled environmental conditions. Irradiated and nonirradiated PRBCs were administered in triplicate by the gravitational method and 10-mL/hour syringe infusion pump, in peripheral intravenous catheter, Vialon, 24-G caliber. Aliquots were collected directly from the PRBC bag, after manual filling of the infusion system and after infusion by the catheters. The following hemolytic markers were analyzed: degree of hemolysis (%), hematocrit (Ht, %), free hemoglobin (fHb, g/dL), potassium (K, mmol/L), and lactate dehydrogenase (LDH, U/L). Mann-Whitney and Student's t tests were used, P ≤ .05. The gravitational method significantly influenced increasing fHb (P = .007), Ht (P = .002), K (P = .002), and LDH (P = .003) values after PRBC irradiated infusion. The infusion of irradiated and non-irradiated PRBCs interferes with changes in hemolytic markers with the gravitational method. Syringe infusion pump proved to be a beneficial and safe alternative to irradiated and nonirradiated PRBC transfusion in newborns.

Neonatal Platelet Transfusions: Starting Again.

Preterm neonates with severe thrombocytopenia are frequently prescribed prophylactic platelet transfusions despite no evidence of benefit. Neonatal platelet transfusion practice varies, both nationally and internationally. Volumes and rates of transfusion in neonatology are based on historic precedent and lack an evidence base. The etiology of harm from platelet transfusions is poorly understood. Neonates are expected to be the longest surviving recipients of blood produce transfusions, and so avoiding transfusion associated harm is critical in this cohort. This article reviews the evidence for and against platelet transfusion in the neonate and identifies areas of future potential neonatal platelet transfusion research.

Implementation of a neonatal platelet transfusion guideline to reduce non-indicated transfusions using a quality improvement framework.

ObjectiveVariation exists in neonatal platelet transfusion practices. Recent studies found potential harm in liberal platelet transfusion practices, supporting the use of lower transfusion thresholds. Our aim was to reduce non-indicated platelet transfusions through implementation of a restrictive platelet transfusion guideline.Study designPlatelet transfusions from January 2017 to December 2019 were classified as indicated or non-indicated using the new guideline. Interventions included guideline implementation and staff education. Outcomes were evaluated using statistical process control charts. Major bleeding was the balancing measure.ResultDuring study, 438 platelet transfusions were administered to 105 neonates. The mean number of non-indicated platelet transfusions/month decreased from 7.3 to 1.6. The rate of non-indicated platelet transfusions per 100 patient admissions decreased from 12.5 to 2.9. Rates of major bleeding remained stable.ConclusionsImplementation of a restrictive neonatal platelet transfusion guideline significantly reduced potentially harmful platelet transfusions in our NICU without a change in major bleeding.

Closing the evidence to practice gap in neonatal transfusion medicine

Significant resources are directed towards world-class research projects, but the findings are not necessarily translated into better healthcare outcomes, either at all or in a sustained way. There is a clear need to dedicate further resources to understanding how to promote the uptake of evidence and effectively change neonatal transfusion practice to improve outcomes. Approaching blood transfusion behaviour change more systematically, and working across disciplines and involving families, holds the potential to increase the rate of uptake of emerging evidence in clinical practice. This approach holds the potential to save costs, conserve resources, and improve clinical outcomes. Our paper focuses on the use of quality improvement to bridge the gap between evidence-based knowledge and transfusion practice in neonatal units around the world.

Blood Component Transfusion in Tertiary Care Neonatal Intensive Care Unit and Neonatal Intermediate Care Unit: An Audit.

BackgroundNeonates admitted in a tertiary neonatal intensive care unit (NICU) require multiple blood transfusions because of extended NICU stay and repeated sampling. The rookie organ systems and miniature blood volumes in the neonate call for regular audits in neonatal blood transfusion practice. Sharing component usage data with the blood bank will prepare them to store components according to demand, thus limiting wastage of components as well as make banks ready to face a shortage in case of ramped up requirements.ObjectiveAuditing neonatal blood transfusion indications and identifying the most commonly used component.MethodologyThis retrospective cohort study was conducted by the department of pediatrics over 22 months from February 20, 2017, to December 30, 2018. Any preterm and term neonates admitted to the NICU and Neonatal Intermediate Care Unit (NIMC) and receiving any transfusion, i.e., fresh frozen plasma (FFP), red cell concentrate (RCC), platelets, and exchange transfusion were included in our study. We collected data from the medical records of NICU and NIMC admitted patients receiving blood component transfusions from 2011 to 2016. Patients were categorized according to the classification of neonatal conditions by the International Classification of Diseases 11th Revision (ICD-11). There were no exclusion criteria. A descriptive statistical analysis was done, and a Chi-square test was applied.ResultsOut of 340 neonates, 249 (73.2%) were low birth weight, 139 (40.9%) were small for gestational age (SGA), and 277 (81.5%) neonates required transfusion during the first week of life. The majority of neonates require multiple transfusions. Fourteen(4.12%) neonates required up to 10 transfusions, two neonates required up to 22 transfusions, and 58 neonates required more than five blood transfusions. The majority required transfusion due to neonatal sepsis, Disseminated intravascular coagulopathy, low birth weight, respiratory distress syndrome, and unconjugated hyperbilirubinemia. Thirty-seven point eighty-two percent (37.82%) transfusions were fresh frozen plasma, 31.34% transfusions were red cell concentrate, 28.14% transfusions were platelet concentrate, and 2.70% were whole blood. Out of 340 neonates, 317 survived and were discharged.ConclusionThe most commonly transfused component was fresh frozen plasma, the indication was neonatal sepsis, and the group was preterm. Whole blood is still being used and needs to be stopped.

Approaches to understanding and interpreting the risks of red blood cell transfusion in neonates.

In this review, we explore how to assess potential harm related to neonatal transfusion practice. We consider different sources of information, including passive or active surveillance systems such as registries, observational studies, randomised trials and systematic reviews. Future research directions are discussed.

Anemic Conditions Acceptable in Restrictive Transfusion Practice Induce Gut Inflammation and Injury in an Animal Model of Preterm Infants

Very low birth weight (VLBW) infants often require multiple transfusions within the first weeks of life. In an effort to minimize transfusion-associated risks, many neonatologists have opted for more restrictive neonatal transfusion practices. However, whether a restrictive transfusion strategy is effective in limiting transfusions without increasing morbidity and mortality in this population remains unclear. Recently, the increasing use of more restrictive neonatal transfusion practices has been associated with a concomitant increase in the incidence of necrotising enterocolitis (NEC) in VLBW infants. Retrospective studies and a meta-analysis of trials comparing restrictive vs. liberal transfusion strategies suggest a higher risk of NEC among preterm infants managed by restrictive transfusion approaches (pooled relative risk 1.6; 95% CI 0.8-3.1). A recent multicenter, prospective observational study evaluating time-varying exposure to anemia also reported a higher risk of NEC among infants with severe anemia compared to those without severe anemia (adjusted hazard ratio 6.0; 95% CI 2.0-18.0). Importantly, while previous studies suggest that transfusion itself may cause transfusion-associated gut injury (TRAGI), this study failed to find an association between transfusion and NEC, strongly suggesting that anemia itself may represent a key risk factor linking increased incidence of NEC to restrictive transfusion practices.To determine whether anemia may directly affect the development of NEC we employed a pre-clinical murine model that utilizes gradual phlebotomy-induced anemia (PIA). Pups were bled twice-daily (5mL/g) beginning at postnatal day 3 (P3) to achieve a hematocrit of 23-25% by P7. Anemic and littermate control pups were then examined for intestinal hypoxia, inflammation and gut barrier disruption at P8. Levels of intestinal hypoxia were evaluated by injection of hypoxyprobe (Hypoxyprobe, Inc.) into control and anemic pups, followed by sacrifice at 1 hour post-injection and detection of protein adducts of pimonidazole in hypoxic tissue by confocal analysis. Inflammation was assessed by evaluation of key immune populations, including macrophages, dendritic cells and T cells for number and function by flow cytrometry. Finally, gut barrier function was assessed by quantification of fluorescein isothiocyanate (FITC)-dextran (4kDa) in the serum 4 hours following oral gavage.While hypoxia within the gut is normally confined to the lumen, neonatal pups exhibited significant increases in gut hypoxia following PIA, which extended beyond the gut lumen to intestinal crypts where key immune populations reside. Comparative analysis of immune populations in the gut between control and anemic neonates indicated no impact of PIA on macrophage, dendritic cell or T cells numbers. However, gut resident macrophages in anemic mice produced significantly more IFNg compared to controls. In contrast, no changes in dendritic cell or T cell cytokine production were observed, strongly suggesting that gut resident macrophages may play a primary role in anemia-induced increases in intestinal inflammation. As inflammation can directly impact gut barrier function, we next investigated intestinal barrier permeability as a marker of gut injury that may precede NEC. When FITC-dextran was administered by oral gavage to anemic and control mice, followed by quantification in the blood 4 hours later, significantly higher blood levels of FITC-dextran could be detected in anemic recipients, demonstrating increased intestinal barrier permeability following PIA.While physiological hypoxia in healthy individuals is localized to epithelial cells adjacent to the lumen, our data demonstrate hypoxic staining throughout the mucosa in neonates following PIA. Additionally, PIA appears to increase macrophage pro-inflammatory cytokine secretion and also compromises gut barrier function, both key factors that can predispose neonates to NEC. Thus, data from this preclinical model suggest that restrictive transfusion guidelines which allow for hematocrits as low as ~24% prior to transfusion may increase morbidity and mortality associated with NEC in preterm infants. DisclosuresNo relevant conflicts of interest to declare.

Audit of Red Cell Transfusions in the Neonatal Intensive Care Unit, Rotunda Hospital 2011-2015

Introduction/BackgroundNeonates are an intensively transfused group of vulnerable patients. Neonatal transfusion practice and general care has evolved over recent years, including the introduction of pedi-packs to limit donor exposure, and it remains important to audit practice. Inappropriate transfusions expose babies to potential adverse effects of transfusion. A national audit performed in the UK in 2010 concluded that there is a lack of evidence to back many of the existing recommendations for neonatal transfusion.We undertook a prospective audit in order to review 5 years of transfusion practice in a tertiary NICU. Our current neonatal transfusion guidelines are based upon internationally published guidelines.Aims & Objectives:To determine the number of babies transfused, whether transfusions were adherent to local guidelines, to identify areas requiring improvement and to determine whether continuous auditing and feedback to clinicians improves practiceMethodology/Interventions This was a prospective audit conducted over a 5 year period. Data were prospectively and retrospectively retrieved from patient charts and electronic databases. Data were stored in a password-protected excel spreadsheet created on a secure hospital network.Results and Discussion A total of 557 babies were transfused with red cells during the period 2011 -2015, representing 7-12% of babies admitted to NICU. The median number of transfusions decreased in babies of all birth weight categories between 2011-2015. The biggest change was in babies <750g, where median donor exposure was reduced from 2 to 1 during this time. The overall percentage of babies admitted to NICU requiring a blood transfusion reduced from 12% to 7%. The most significant reduction was seen in babies ≥1500g with a reduction from 4% in 2011 to 2% in 2015.Conclusions Auditing of neonatal transfusion especially in the area of pedi-pack top up transfusions highlighted specific areas where improvements could be made. This includes adherence to guidelines, consultant-led decision to transfuse (when time permits), and on-going audit and feedback to clinicians. These measures along with a multi-disciplinary approach to blood management have seen an overall reduction in percentage of babies being transfused without compromising the well-being of the baby. This has led to a reduction of donor exposure to the baby and a reduction in the cost and workload across all disciplines of staff associated with blood transfusion leading to an overall improvement to patient safety and quality of care. Despite this, the transfusion rate in babies of < 1000g remains the highest however this would be expected given the overall clinical needs of babies in this birth weight category. [Display omitted] [Display omitted] DisclosuresNí Áinle:Actelion UK: Research Funding.

Research Opportunities to Improve Neonatal Red Blood Cell Transfusion.

Red blood cell (RBC) transfusion is a common and lifesaving therapy for anemic neonates and infants, particularly among those born prematurely or undergoing surgery. However, evidence-based indications for when to administer RBCs and adverse effects of RBC transfusion on important outcomes including necrotizing enterocolitis, survival, and long-term neurodevelopmental impairment remain uncertain. In addition, blood-banking practices for preterm and term neonates and infants have been largely developed using studies from older children and adults. Use of and refinements in emerging technologies and advances in biomarker discovery and neonatal-specific RBC transfusion databases may allow clinicians to better define and tailor RBC transfusion needs and practices to individual neonates. Decreasing the need for RBC transfusion and developing neonatal-specific approaches in the preparation of donor RBCs have potential for reducing resource utilization and cost, improving outcomes, and assuring blood safety. Finally, large donor-recipient-linked cohort studies can provide data to better understand the balance of the risks and benefits of RBC transfusion in neonates. These studies may also guide the translation of new research into best practices that can rapidly be integrated into routine care. This review highlights key opportunities in transfusion medicine and neonatology for improving the preparation and transfusion of RBCs into neonates and infants. We focus on timely, currently addressable knowledge gaps that can increase the safety and efficacy of preterm and term neonatal and infant RBC transfusion practices.

Temporal changes in blood product usage in preterm neonates born at less than 30 weeks' gestation in Canada.

Knowledge of neonatal transfusion practices remains limited to local cohorts or survey-based studies. This study evaluated the pattern and temporal changes in the types and frequency of blood product use among preterm neonates born at less than 30 weeks' gestation in Canada. A retrospective cohort study of preterm neonates born at less than 30 weeks' gestation and admitted to participating neonatal intensive care units in the Canadian Neonatal Network from 2004 to 2012 was conducted to evaluate blood product usage. The temporal change in red blood cell (RBC) use was evaluated by dividing the study period into three epochs: 2004 to 2006, 2007 to 2009, and 2010 to 2012. Of 14,868 eligible neonates admitted to participating units in Canada during the overall study period, 8252 (56%) received RBCs, 2151 (15%) platelets, 1556 (11%) fresh-frozen plasma, 915 (6%) albumin, and 302 (2%) cryoprecipitate. Temporal evaluation over three epochs revealed a trend toward fewer RBC transfusions among neonates born at 26 to 29 weeks' gestation (p=<0.01-0.04) but use remained unchanged or increased for neonates born at 23 to 25 weeks' gestation (p=0.02-0.54). Blood product use remains at a very high frequency in preterm neonates born at less than 30 weeks' gestation. Evolutionary practice changes and relative high tolerance for anemia may be associated with a reduction in RBC usage in recent years in neonates born at at least 26 weeks' gestation. This contrasts with the ongoing higher usage of blood products observed at extremely low gestational ages.

Neonatal platelets: mediators of primary hemostasis in the developing hemostatic system.

The human hemostatic system is developmentally regulated, resulting in qualitative and quantitative differences in the mediators of primary and secondary hemostasis as well as fibrinolysis in neonates and infants. Although gestational age-related differences in coagulation factor levels occur, the existence of a unique neonatal platelet phenotype remains controversial. Complicated by difficulties in obtaining adequate neonatal blood volumes with which to perform functional assays, ambiguity surrounds the characterization of neonatal platelets. Thus, much of the current knowledge of neonatal platelet function has been based on studies from cord blood samples. Studies suggest that cord blood-derived platelets, as a surrogate for neonatal platelets, are hypofunctional when compared with adult platelets. This relative platelet dysfunction, combined with a propensity toward thrombocytopenia in the neonatal intensive care unit population, creates a clinical conundrum regarding the appropriate administration of platelet transfusions. This review provides an appraisal of the distinct functional phenotype of neonatal platelets. Neonatal platelet transfusion practices and the impact of the relatively hypofunctional neonatal platelet on those practices will be considered.

Red blood cell transfusions in very low birth weight newborns

It has been reported that 80% of very low birth weight infants (VLBWI) are receiving packed red blood cell transfusions (PRBCtr), and in 90% of cases, the indication is the replacement of the blood collected. The existence of guidelines for transfusion practices has had a great impact on the decline in the number of transfusions. The aim of this paper is to describe the characteristics of VLBW infants who are packed red blood cell transfusion receptors. This is a descriptive cross-sectional study, which included the medical records of all VLBW newborns older than 72 hours, released from the Neonatology department of the Hospital Valdivia Base, between 2005 and 2006. Birth weight, gestational age, pulmonary surfactant, hyaline membrane, mechanical ventilation, bronchopulmonary dysplasia, sepsis and packed red blood cell transfusions were evaluated. Guidelines for packed red cell transfusions were used at the Hospital. 93 newborns were evaluated and 62 of them were transfused (66.7%); they received 2.1 ± 0.9 PRBC transfusion and the exposure to different donors was 2.1 ± 0.9. The VLBW infants susceptible to be PRBCtr receptor were those younger than 30 weeks' gestational age, weighing less than 1,250 g and with respiratory failure, mechanical ventilation and sepsis. The observed percentages of transfused infants with very low birth weight, median PRBCtr and exposure to different donors can be attributed to the existence of guidelines for neonatal transfusion practices and a team of highly experienced neonatologists.

Comparison of Outcomes of Group O vs Non–Group O Premature Neonates Receiving Group O RBC Transfusions

At some institutions all infants requiring RBC transfusions in neonatal intensive care units (NICUs) receive only group O RBCs. Although transfused group O plasma is minimized in packed RBCs, small amounts of residual anti-A, anti-B, and anti-A,B in group O packed RBCs may bind to the corresponding A and B antigens of non-group O RBCs, possibly hemolyzing their native RBCs and thereby releasing free hemoglobin, theoretically resulting in hypercoagulability and promoting bacterial growth from free iron. Premature infants in the University of Kentucky Children's Hospital NICU database who were transfused (all received group O transfusions) were compared for a number of severity markers to determine if non-group O patients had worse outcomes than group O patients. In this NICU sample, 724 neonates received at least 1 blood component. No significant differences were found between group O and non-group O infants with regard to final disposition or complications. This reassuring finding validates the longstanding neonatal transfusion practice of using group O packed RBCs for infants of all blood groups in the NICU. However, a recent study shows increased mortality from necrotizing enterocolitis in group AB neonates at a facility transfusing only group O RBCs to neonates of all blood groups and suggests a change in neonatal transfusion practice to ABO group-specific RBCs; therefore more studies may be warranted.

Transfusion Practices and Infections At Four Level III Neonatal Intensive Care Units

IntroductionTransfusions of packed red blood cell (pRBC) units to infants in Neonatal Intensive Care Units (NICUs) may predispose neonates to healthcare-associated infections (HAIs). We compared neonatal pRBC transfusion practices at four NICUs (Morgan Stanley Children's Hospital of NewYork-Presbyterian, Columbia University Medical Center, Komansky Children's Hospital of Weill Cornell Medical Center, Christiana Care Health System, and Children's Hospital of Philadelphia). In addition, because prolonged refrigerator storage of pRBC may further predispose to HAIs, we tested the hypothesis that an increased mean RBC storage age was associated with a greater risk of infections. DesignThe interdisciplinary NICU Antimicrobial Prescribing (iNAP) study was conducted in four Level III NICUs from May 2009 to April 2012 to assess HAIs and improve antimicrobial prescribing in NICUs. Eligible infants were admitted <7 days of age and hospitalized ≥4 days. Demographic (e.g., sex, birth weight [BW]) and clinical data (e.g., HAIs and surgical procedures) were collected. HAI included culture negative sepsis defined by treating clinicians, necrotizing enterocolitis, or bacteremia treated for ≥ 4 days. pRBC transfusions were collected from blood bank records at each site. Descriptive statistics were performed using GraphPad Prism 6. ResultsAll sites used irradiated, leukoreduced, CMV negative pRBCs and practiced donor limitation. Blood bank preparation procedures were similar at all sites except that one site stored 3% of units in CPDA-1 in addition to units stored in Additive Solutions (AS), and another site irradiated the parent unit instead of the aliquot; the other sites irradiated the aliquot prior to release. During the study period, 6411 pRBC transfusions were administered to 1381 (21.5%) of 6184 enrolled infants. The transfusion rate was 12.6%, 37.3%, 16.7%, and 25.1% at sites 1-4, respectively. The rate of transfusion by normal BW (≥2500g), low BW (1500-2499g), very LBW (<1500g), and extremely LBW (<1000g) was 0.8, 0.4, 2.8, and 5.5 per patient, respectively. Transfused infants received an average of 4.7 transfusions (range 1-63; average of 3.5, 4.5, 4.5, and 6.0 transfusions at each respective site) with a mean donor exposure of 2.1 (range 1-23). Overall, 50% of pRBC transfusions occurred in the first 17 days of life and 34% occurred during the first week of life. Surgical and post-surgical transfusions accounted for 1389 (21.7%) of 6411 transfusions in 486 (35%) of 1381 transfused infants. Infants undergoing congenital diaphragmatic hernia repair required the most transfusions; 34 infants received 537 ECMO-related transfusions. The average storage age of the pRBC transfused was 16.1 days, but differed by site (12.5, 14.6, 16.7, 19.9 days for each site, respectively, p< 0.001 by Kruskal-Wallis test with Dunns Multiple Comparison Test) and by aliquot (1st-5th aliquot average age 12, 16, 19, 21, and 23 days, respectively). The average age of units transfused in infants without HAIs (n=5693) was 15.2 days; while the average age of units transfused in infants with HAIs (n=491) that developed after transfusion was 15.4 (p=0.04). An ecological study comparing all sites did not find a significant association between the average storage age of units transfused per site (excluding units transfused after onset of infection) and the proportion of neonates with HAIs at the site (R2=0.29; p=0.46; see Figure). [Display omitted] ConclusionsTo our knowledge, this is the largest cohort study of neonatal transfusion practices in Level III NICUs. Transfusion practices were similar at each site. The average storage age of transfused pRBC units varied among the four sites; however, the mean RBC storage age of RBCs transfused to patients with or without HAIs was not markedly different and hospitals with a longer mean storage age did not have a higher proportion of neonates with HAIs. Further analysis is needed to explore the relationship between pRBC storage and HAIs, while controlling for differences in patient characteristics. Disclosures:No relevant conflicts of interest to declare.

Donor exposure in neonatal blood transfusion - time to change strategy?

<h3>Background</h3> Previous studies have recommended reserving 8 satellite packs (SP) for extremely low birth weight (ELBW) babies to reduce donor exposure (DE) from blood transfusions.1 However, concentration of transfusions at the beginning and end of neonatal care coupled with short shelf-life of blood result in wastage of SPs and unavoidable DE. Neonatal transfusion practice may have changed due to restrictive transfusion guidelines, micro-sampling methods and practice of delayed cord clamping. We currently reserve only 4 SPs for ELBW babies and strictly follow British Committee for Standards in Haematology 2004 guidelines for blood transfusion². <h3>Aims</h3> To ascertain the root cause of excess DE and SP wastage in multi-transfused ELBW babies and suggest an optimum contemporary strategy that would balance DE with SP wastage. <h3>Methods</h3> Transfusion data was collected for all inborn ELBW babies and those transferred-in within 96 hours of birth in 2010. Rates and determinants of DE were analysed. Projected SP wastage and DE rates were calculated for different SP strategies. <h3>Results</h3> Thirty-eight ELBW babies with a mean gestation of 25.5 weeks and birth weight of 712 grams were included. Eight babies were not transfused while 7 received only one transfusion. Therefore, 23 babies were included for DE and 30 for SP wastage analysis. The mean SP usage was 3.97/baby. The mean DE was 2.47 and mean SP wastage 4.7/baby. The mean age of the donor unit at allocation was 20.2 days (95% CI 18.4, 22). The mean interval between the first and last transfusion was 35 days. Reducing donor unit age to 14 days at allocation would have reduced one donor exposure in 11/23 babies (47.8%). Table 1 shows the effect of different projected SP strategies on DE and SP wastage. <h3>Conclusions</h3> Younger age of blood unit at allocation is the key to reduce DE. A 4-SP strategy appears appropriate for current transfusion practice for ELBW babies.