How we decide when a neonate needs a transfusion

Abstract

SummaryThe decision to transfuse a neonate can be approached by addressing a series of questions that cover the cause of anaemia, alternatives to transfusion, the need for transfusion and the risks. Recent clinical trials of red cell transfusions have started to inform evidence-based transfusion practice, but have raised uncertainties about neurological outcomes when policies advocating use of fewer red cell transfusions at lower haemoglobin concentration (Hb) thresholds were tested. Red cell transfusions should be considered when the Hb <120 g/l for premature neonates requiring mechanical ventilation support, with lower thresholds applying for oxygen-dependent neonates not requiring ventilation or for late anaemia (Hb <70-100 g/l, depending on gestational and post-natal age). There is no recent high quality evidence to inform thresholds for prophylactic platelet transfusions in stable non-bleeding premature neonates with platelet count levels of 50 9 10 9 /l, although common practice has become more restrictive, using lower safe thresholds for platelet transfusion between 20 and 30 9 10 9 /l. A more appropriate transfusion strategy for fresh frozen plasma (FFP) in neonates is one that emphasizes the therapeutic use of FFP in the face of bleeding, rather than prophylactic use in stable non-bleeding neonates who often have mild to moderate apparent abnormalities of standard coagulation tests, after allowing for appropriate reference ranges.

Coagulation indices in very preterm infants from cord blood and postnatal samples

“…3A and B). Mean (SD) preterm peak thrombin generated was similar to that measured in term infants (126.3 [36.1] vs. 116.1 [22] nM; P = 0.38; Fig. 3C).…”

Evidence-Based Advances in Transfusion Practice in Neonatal Intensive Care Units

“…von Lindern et al [61,62] conducted such an analysis in the Netherlands, finding the NICUs with higher platelet transfusion usage did not have lower odds of clinical hemorrhage. Studies by Sola-Visner [52], Ferrer-Marin et al [63] and Venkatesh et al [57] reported somewhat similar findings. Basically, no difference in IVH or other significant hemorrhagic complications were observed among neonates with platelet counts in the 20,000-40,000 platelets/µl range compared with neonates whose counts were in the 40,000-60,000/µl range.…”

“…In current neonatology practice, when a transfusion is contemplated, the neonatologist will generally contextualize the best treatment by integrating his/her own past clinical experiences with information recently acquired from reliable sources [2,3,4,5,6,7]. However, progress toward better outcomes and cost containment requires that this process be replaced by a new paradigm of evidence-based decision making [1].…”

“…However, as shown in table 5, the guidelines suggested by Stanworth et al [56] and Venkatesh et al [57] from England are very similar to the guidelines of Intermountain Healthcare in the western USA [58,59]. These advocate that a stable NICU patient would receive a platelet transfusion only if the platelet count falls below 20,000 platelets/µl, while a patient on extracorporeal membrane oxygenation or immediately before or after an operation would be transfused if the count falls below 100,000 platelets/µl.…”

Intraoperative fluid therapy in neonates

“…[75][76][77] There is controversy about what fluid to give before blood is transfused in neonates. In a survey to members of the Association of Paediatric Anaesthetists (APA) and the French-language Society of Paediatric Anaesthesiologists (ADARPEF), a majority of both the APA (90%) and ADARPEF (81%) preferred the use of albumin for the replacement of perioperative fluid losses in premature and term neonates.…”