Blood transfusion for anaemia of prematurity: Current practice in Australia and New Zealand

Abstract

Aim To characterise the current transfusion practice among clinicians in Australasian neonatal units and factors that influence their decision‐making. Methods Members of the Australia and New Zealand Neonatal Network (ANZNN) and practitioners at their local institutions were invited to participate in a 15‐question web‐based survey between 1 June and 31 July 2016. The survey was designed to assess (i) haemoglobin‐based transfusion thresholds; (ii) presence of local guidelines; (iii) preference for a restrictive or liberal transfusion policy; (iv) perceived benefits and risks of transfusion; and (v) use of clinical adjuncts to assist decision‐making. Results Overall, 130 participants responded to at least one question. Haemoglobin transfusion thresholds for anaemia of prematurity (AOP) varied significantly from <60 to <120 g/L. Of 103 participants, 36 (35%) reported that they do not have access to local transfusion guidelines. The majority utilise multiple clinical and haematological parameters to guide their decision‐making, and approximately half (45/84, 54%) believe that tissue hypoxia detected by near‐infrared spectroscopy (NIRS) may better inform transfusion thresholds. Of 102 participants, 51 (50%) support a restrictive rather than liberal transfusion policy. The most commonly reported perceived risks of transfusion for AOP were suppression of endogenous erythropoiesis and increased rates of necrotising enterocolitis. Conclusions There is a significant variation in transfusion practice in Australasian neonatal units. Quality and safety initiatives may assist with improved consistency of transfusion practice across the ANZNN. However, further research is required to better define optimal transfusion thresholds, quantify potential risks of transfusion and determine clinical utility of newer adjuncts such as NIRS.

Management of anaemia in pre‐term infants

“…Thus, younger infants on more invasive respiratory support receive RBC transfusions at a higher threshold than older infants who are almost ready for discharge (Table ). In addition, neonatologists may utilise clinical signs and symptoms of anaemia to determine whether RBC transfusion is indicated (Saito‐Benz et al , ). Pre‐term infants who demonstrate increased frequency and duration of apnoea and bradycardic episodes, increased oxygen requirements, unexpected escalation of respiratory support, poor feed tolerance and growth, pallor or reduced activity may be considered to have symptomatic anaemia in need of RBC transfusion (Keyes et al , ).…”

“…However, these symptoms are highly non‐specific and may be caused by a number of other conditions, including chronic lung disease, sepsis and other pre‐term‐associated morbidities. Although RBC transfusion to treat ‘symptomatic’ anaemia of prematurity is well intended, many neonatologists report no objective clinical improvement following transfusion (Saito‐Benz et al , ).…”

“…Despite a century of research and clinical advances, there is a paucity of evidence to accurately inform the risks and benefits of these so‐call ‘top up’ transfusions. Consequently, wide practice variation is observed between clinicians, centres and countries with regards to neonatal transfusion, often reflecting expert opinion rather than a scientifically robust evidence base (Guillen et al , ; Saito‐Benz et al , ).…”

Embedding best transfusion practice and blood management in neonatal intensive care

“…It is essential that processes are in place to ensure safe and appropriate transfusion decision-making, consent, documentation and administration in this vulnerable population. However, in a recent study, Australian and New Zealand neonatal units were found to have significant variation in red cell clinical transfusion practices and local policies 9. This PBE-CPI project confirmed the varied practice and inconsistent documentation practices in the NICU.…”

Liberal hemoglobin threshold affects cerebral arterial pulsed Doppler and cardiac output, not cerebral tissue oxygenation: a prospective cohort study in anemic preterm infants

“…Despite a growing body of research on RBC transfusion practices, the literature reports significant variation in practices on the following issues: choosing the optimal threshold at which to administer the RBC transfusion (restrictive vs. liberal vs. historical recommendations such as maintaining Hb above 10 g/L in unwell preterm infants); use of Hct versus Hb levels as a trigger to initiate transfusion; and incorporation of noninvasive bedside monitoring devices to aid clinical decision making.…”