Neonatal red blood cell transfusions: searching for better guidelines

Packed red blood cell (RBC) transfusions are often administered to patients in the neonatal intensive care unit. The purpose of this study was to determine whether current blood transfusion guidelines are as useful as care givers' perception in identifying patients in need of a packed RBC transfusion.

Health care providers were asked to complete a pre- and post-transfusion survey on neonates receiving a packed RBC transfusion. These patients were divided into three groups based on reasons for transfusion: (i) guidelines; (ii) care-givers' perceptions of need for packed RBC transfusion; or (iii) both. These three groups were further subdivided into two cohorts according to whether they had a clinical improvement or not. Demographic data and clinical variables were compared between the groups.

Seventy-eight care-givers were surveyed. Eighteen patients (23%) were transfused based on guidelines, 36 (46%) based on care givers' perception and 24 (31%) based on both. Neonates transfused based on guidelines alone were more likely to have received the transfusion in the first week of life, had a higher pre-transfusion haematocrit, were less symptomatic and had a higher trend to require mechanical ventilation. Neonates transfused based on caregivers' perception were more likely to be on non-invasive ventilatory support and were more symptomatic. Neonates who improved after a transfusion had a lower pre-transfusion haematocrit (p=0.02), were more symptomatic (p=0.01) and were more likely to be on non-invasive ventilatory support (p=0.002) when compared to the group without a clinical improvement. The group without improvement had an increase in oxygen requirement (+2.8±6.4) after the transfusion (p=0.0004). Tachycardia was the most sensitive predictor of a benefit from packed RBC transfusion [OR 6.48: p=0.005].

Guidelines on when to transfuse stable growing neonates with packed RBC should be re-evaluated to include more care giver judgement and perhaps be more restrictive for critically ill neonates.