International Survey of Transfusion Practices for Extremely Premature Infants

doi:10.1053/j.semperi.2012.04.004

Seminars in Perinatology

Volume 36, Issue 4, August 2012, Pages 244-247

https://doi.org/10.1053/j.semperi.2012.04.004 Get rights and content

Our objective was to survey neonatologists regarding international practice of red cell transfusion thresholds for premature infants with <1000-g birth weight and/or <28-week gestation. An invitation to fill out an 11-question web-based survey was distributed to neonatologists through their professional societies in 22 countries. Physicians were asked about which specific factors, in addition to hemoglobin levels, influenced their decisions about transfusing premature infants. These factors included gestational age, postnatal age, oxygen need, respiratory support, reticulocyte count, and inotropic support. Physicians were presented with 5 scenarios and asked to identify hemoglobin cutoff values for transfusing infants with <1000-g birth weight and/or <28-week gestation. One thousand eighteen neonatologists responded: the majority were from the United States (67.5%), followed by Germany (10.7%), Japan (8.0%), the United Kingdom (4.9%), Spain (3.9%), Italy (2.6%), Colombia (0.6%), Argentina (0.4%), Canada (0.4%), Belgium (0.1%), and the Netherlands (0.1%). Half of the respondents (51.1%) reported having a written policy with specific red cell transfusion guidelines in their unit. Factors considered “very important” regarding the need to administer blood transfusions included degree of oxygen requirement (44.7%) and need for respiratory support (44.1%). Erythropoietin was routinely used to treat anemia by 26.0% of respondents. Delayed cord clamping or cord milking was practiced by 29.1% of respondents. The main finding was of a wide variation in the hemoglobin values used to transfuse infants, regardless of postnatal age. Step-wise increments in the median hemoglobin cutoffs directly paralleled an increase in the need for levels of respiratory support. In the first week of life, there was a wider range in the distribution of hemoglobin transfusion thresholds for infants requiring no respiratory support and full mechanical ventilation compared with the thresholds used in the second, third, and fourth weeks of life. An international survey using hypothetical scenarios shows that red blood cell transfusion practices vary widely among practicing neonatologists in participating countries.

Section snippets

Methods

Neonatologists in 22 countries were invited to fill out an 11-question web-based survey via Survey Monkey (SurveyMonkey.com, LLC, Palo Alto, CA; www.surveymonkey.com). For each country, nominated collaborators were asked to forward a letter of invitation to take part in a neonatal red cell transfusion survey to all eligible neonatal physicians. Physicians were asked to identify their country of practice, whether their unit had standard guidelines for transfusion, whether they routinely used

Results

One thousand eighteen neonatologists from 11 countries responded with the majority from the United States (67.5% of neonatologists), followed by Germany (10.7%), Japan (8.0%), the United Kingdom (4.9%), Spain (3.9%), Italy (2.6%), Colombia (0.6%), Argentina (0.4%), Canada (0.4%), Belgium (0.1%), and the Netherlands (0.1%). Half of the respondents (51.1%) reported having a written policy with specific red cell transfusion guidelines in their unit. Erythropoietin was routinely used by 26.0% of

Discussion

Red blood cell transfusion practices vary widely among practicing neonatologists worldwide. The current available data to guide clinical management of red blood cell transfusions in extremely premature infants are limited. Two moderate-sized, randomized trials have compared restrictive versus liberal transfusion criteria in extremely low-birth-weight infant population: the Iowa and PINT trials.17, 18 Both trials used transfusion thresholds that varied with patient status, respiratory support,

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Evidence-Based Neonatal Transfusion Guidelines
2023, Principles of Neonatology
Pathologic anemia is defined by an inadequate red blood cell mass that fails to meet the oxygen needs of tissues. Neonates often require red cell transfusions due to a decreased red cell mass brought about by acute blood loss. Preterm infants frequently experience a decline in red cell mass due to phlebotomy, a shortened red cell life span, and lack of erythropoietic response to a dropping hematocrit due to lack of erythropoietin production, termed the anemia of prematurity. Target hemoglobin and hematocrit have been used as an indicator for a red cell transfusion in preterm neonates. Recently published data from two large multicenter trials in Europe and the United States show that a restrictive approach (using a lower hematocrit to trigger a transfusion) results in fewer transfusions and does not increase the risk of death or serious neurodevelopmental impairment. Individualized markers for transfusion need, beyond hematocrit triggers, that optimally balance the risks and benefits of transfusion continue to be investigated and will serve to improve “transfusion stewardship” (the appropriate and judicious use of red cell transfusions) in the newborn intensive care unit.
Recommendations for transfusion of blood products in neonatology
2022, Anales de Pediatria
La escasa evidencia sobre el uso de las transfusiones en neonatología explica las limitaciones de las guías clínicas actuales. A pesar de ello, en este documento analizamos la evidencia más reciente para hacer unas recomendaciones para la práctica clínica. La prevención de la anemia de la prematuridad, el uso de protocolos y las indicaciones restrictivas de transfusión, componen la mejor estrategia para nuestros clínicos. En las transfusiones de plaquetas, es preciso valorar el riesgo de sangrado, integrando la situación clínica y analítica. Por último, el plasma fresco congelado está recomendado en neonatos con coagulopatía y sangrado activo, en déficits congénitos de factores sin tratamiento específico y en situaciones de coagulación intravascular diseminada. Todos los hemoderivados presentan efectos adversos que deben hacernos evaluar individual y minuciosamente la necesidad de una transfusión.
The scant evidence on the use of transfusions in neonatal care explains the limitations of current clinical guidelines. Despite this, in this document we explore the most recent evidence to make recommendations for the clinical practice. The prevention of anaemia of prematurity, the use of protocols and restrictive transfusion strategies constitute the best approach for clinicians in this field. In the case of platelet transfusions, the risk of bleeding must be assessed, combining clinical and laboratory features. Lastly, fresh frozen plasma is recommended in neonates with coagulopathy and active bleeding, with congenital factor deficiencies for which there is no specific treatment or with disseminated intravascular coagulation. All blood products have adverse effects that warrant a personalised and thorough assessment of the need for transfusion.
Variation in Neonatal Transfusion Practice
2021, Journal of Pediatrics
To estimate the incidence of blood product transfusion, including red blood cells, platelets, and plasma, and characterize pretransfusion hematologic values for infants during their initial hospitalization after birth.
Retrospective cohort study using data from 7 geographically diverse US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) from 2013 to 2016. Pretransfusion hematologic values were evaluated closest to each transfusion and no more than 24 hours beforehand.
Data from 60 243 infants were evaluated. The incidence of any transfusion differed by gestational age (P < .0001), with 80% (95% CI 76%-84%) transfused at <27 weeks of gestation (n = 329) and 0.5% (95% CI 0.5%-0.6%) transfused at ≥37 weeks of gestation (n = 53 919). The median pretransfusion hemoglobin was 11.2 g/dL (10th-90th percentile 8.8-14.1) for the entire cohort, ranging from 10.5 g/dL (8.8-12.3) for infants born extremely preterm at <27 weeks of gestation to 13.0 g/dL (10.5-15.5) for infants born at term. The median pretransfusion platelet count (×10⁹/L) was 71 (10th-90th percentile 26-135) for the entire cohort, and was >45 for all gestational age groups examined. The median pretransfusion international normalized ratio for the entire cohort was 1.7 (10th-90th percentile 1.2-2.8).
There is wide variability in pretransfusion hemoglobin, platelet count, and international normalized ratio values for neonatal transfusions. Our findings suggest that a large proportion of neonatal transfusions in the US are administered at thresholds greater than supported by the best-available evidence and highlight an opportunity for improved patient blood management.
Blood donation and heavy metal poisoning in developing nations: Any link?
2021, Transfusion and Apheresis Science
Citation Excerpt :
Red blood cells (RBCs) transfusions are often used to manage the anaemia by increasing oxygen delivery to tissues [21]. They are given during the early weeks of life, which is a period of limited excretion via urine and stool and are associated with several adverse effects, including intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity and bronchopulmonary dysplasia [22,23]. This review aims at discussing how the access to a safe and adequate blood transfusion with minimal risk of toxic metals to recipients is a public health challenge, especially in developing nations.
Long term health effects of heavy metal exposure from both occupational and environmental settings involve multi-organ toxicities including but not limited to disturbances of neurological, cognitive, and metabolic processes, immune system dysregulation, carcinogenesis and sometimes permanent disabilities. Humans are exposed to toxic metals through various sources and routes of entry. The risk of heavy metal poisoning from donor blood has been the subject of many scientific investigations. In this review we highlight how the access to a safe and adequate blood transfusion with minimal risk of toxic metals to recipients is a public health challenge, especially in developing nations. For quality assurance purposes, blood donors are screened for various blood-borne pathogens, but screening for toxic metal levels is not routine. Evidence from scientific studies used in this review lends credence to the risk of heavy metal poisoning from donors with high blood concentrations of these heavy metals. The risk of toxicity is exceptionally high in vulnerable populations such as neonates and preterm infants, as well as in pregnant women and other individuals with conditions requiring multiple blood transfusions. This is worse in developing countries where some members of the population engage in illegal refining and artisanal mining activities. In order to reduce toxic metal exposure in vulnerable populations, blood meant for transfusion in vulnerable subjects, e.g. children, should be routinely screened for heavy metal concentrations. Patients receiving multiple blood transfusions should also be monitored for iron overload and its attendant toxicities.

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International Survey of Transfusion Practices for Extremely Premature Infants

Section snippets

Methods

Results

Discussion

J Pediatr

Pediatr Neonatol

Cerebral tissue oxygen saturation and extraction in preterm infants before and after blood transfusion

Arch Dis Child Fetal Neonatal Ed

Blood transfusion effect on the respiratory pattern of preterm infants

Pediatrics

Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants

Pediatrics

Effects of transfusions in extremely low birth weight infants: A retrospective study

J Pediatr

A randomized trial to develop criteria for administering erythrocyte transfusions to anemic preterm infants 1 to 3 months of age

J Perinatol

Empiric red cell transfusion in asymptomatic preterm infants

Acta Paediatr

Red blood cell transfusions are independently associated with intra-hospital mortality in very low birth weight preterm infants

J Pediatr