Transfusion of red blood cells and platelets are commonly performed onneonates in the neonatal intensive care unit (NICU).
Transfusions in the neonatal population areassociated with higher mortality and morbidity when compared to the adultpopulation. Known risks of transfusionsinclude alloimmunization, transfusion reactions and transmission ofinfections. It has also been suggestedthat necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) mayoccur in neonates following a red blood cell transfusion. These risks must be balanced against clinicalneed, especially in the neonatal population. Unfortunately, few clinical trials have been performed to establishguidelines for neonatal transfusions. For this reason, transfusion practices and guidelines widely vary andare sometimes controversial. Thisarticle overviews the need for improving transfusion practices by establishingNICU transfusion guidelines. Current practices involve red cell transfusions that are guided by theneonate’s hematocrit level.
The authorsof this article suggest using more restrictive transfusion hemoglobinthresholds when deciding if transfusion is necessary. The suggested transfusion hemoglobin at 1-7days old is < 11 for ventilated neonates and < 10 fornonventilated neonates. At age 8-14days, the suggested hemoglobin drops to < 9.5 for ventilated neonatesand < 7.5 for neonates without oxygen support. By using these lower thresholds, it is hopedthat the rate of unnecessary transfusions will decline. The article also proposes alternativeprocedures may reduce the need for red cell transfusions in the NICU.
The use of erythropoietin and darbepoetin,which is a long-acting erythropoietin analog, has shown promise in stimulating erythropoiesisin infants and therefore reducing the need for red cell transfusions. In a study performed, one group of neonateswere given darbepoetin once weekly and another group was given erythropoietin 3times a week. Both groups were thencompared to a placebo group and a much lower transfusion rate was noted. The article also suggests delayed cordclamping to reduce the need for neonatal transfusion.
Delaying cord clamping byat least 1 minute can result in an increased hemoglobin after birth. Thrombocytopenia is common inneonates in the NICU with a prevalence of 73% in neonates that weigh less than1,000 g and 85-90% in neonates that weigh less than 750 g. The article states that only 2% of all platelettransfusions in the NICU are appropriately performed due to thrombocytopenicbleeding while the remaining 98% are given for prophylactic measures. Studies have been conducted which comparedbleeding outcomes in neonates who were transfused at platelet counts rangingfrom 40,000-60,000/uL and neonates transfused at more conservative range of20,000-40,000/uL.
Results from these studies showed no significant bleedingdifferences. The authors suggest that amore restrictive platelet transfusion trigger would decrease the number ofplatelet transfusions and therefore minimize risks involved. The authors of this article conclude that a more precise guideline forneonatal platelet and red cell transfusions should be developed to eliminateunnecessary transfusions. This willserve to reduce risks and complications involved with transfusionprocedures. The authors also acknowledgethat, although more restrictive transfusion practices should be implemented,further studies need to be performed to determine whether such procedures wouldhave any adverse effect on long-term neurodevelopment.