Red Blood Cell Transfusion in European Neonatal Intensive Care Units, 2022 to 2023
Authors: Houben Nina A. M. , Fustolo-Gunnink Suzanne , Fijnvandraat Karin , Caram-Deelder Camila , Carrascosa Marta Aguar , Beuchée Alain , Brække Kristin , Cardona Francesco , Debeer Anne , Domingues Sara , Ghirardello Stefano , Grizelj Ruza , Hadžimuratović Emina , Heiring Christian , Krivec Jana Lozar , Malý Jan , Matasova Katarina , Moore Carmel Maria , Muehlbacher Tobias , Szabó Miklos , Szczapa Tomasz , Zaharie Gabriela , de Jager Justine , Reibel-Georgi Nora Johanna , New Helen V. , Stanworth Simon J. , Deschmann Emöke , Roehr Charles C. , Dame Christof , le Cessie Saskia , van der Bom Johanna , Lopriore Enrico ,   International Neonatal Transfusion Point Prevalence Study Group, Alsina-Casanova Miguel , Andersson Ola , Arias-Llorente Rosa Patricia , Berenger Adeline , Bielska Edyta , Boia Marioara , Birkenmaier André , Biros Jakub , Blanquart Anne Laure , Boggini Tiziana , Boileau Pascal , Bokiniec Renata , Bresesti Ilia , Broad Katherine , Cavallaro Giacomo , Chauvel Jennifer , Cseszneki Borbála , Dani Carlo , Demová Klaudia , Dornis Diana , Duban Marie-Pierre , Dziadkowiec-Motyl Karolina , Erzen Nika , Fanczal Eszter , Fernández-Castiñeira Sara , Galuschka Libusa , Gandaputra Ellen , García-Muñoz Rodrigo Fermín , Gebauer Corinna , Grimault Hélène , Grund Kristina , Gsöllpointner Melanie , Gualdi Silvia , Guaragni Brunetta , Hahn Markus , Haiden Nadja , Hasmasanu Monica , Iacob Daniela , Ivanici Mihaela , Jernej Raphaela , Juren Tomáš , Karcz Karolina , Kornhauser Lilijana , Królak-Olejnik Barbara , Legnevall Lena , Lehnerer Verena , Levine Emmanuelle , Ley David , López Castillo María Del Carmen , Magarotto Mariella , Martini Silvia , Maruniak-Chudek Iwona , Moita Rita , Mosuro Anjola , Nowicka Agnieszka , O'Reilly Daniel , Pantea Manuela , Pérez-Muñuzuri Alejandro , Perme Tina , Picciau Laura , Prins Sandra , Radicioni Maurizio , Raffaeli Genny , Roldan-López Reyes , Roué Jean-Michel , Rzepecka Węglarz Beata , Sibrecht Greta , Snijder Pauline , Starčević Mirta , Szántó Emese , Teixeira Liliana , Torrejon Laura , Urquía Martí Lourdes , Vanbuggenhout Laurien , Zanetto Lorenzo 
Published: September 2024

Importance

Red blood cell (RBC) transfusions are frequently administered to preterm infants born before 32 weeks of gestation in the neonatal intensive care unit (NICU). Two randomized clinical trials (Effects of Transfusion Thresholds on Neurocognitive Outcomes of Extremely Low-Birth-Weight Infants [ETTNO] and Transfusion of Prematures [TOP]) found that liberal RBC transfusion thresholds are nonsuperior to restrictive thresholds, but the extent to which these results have been integrated into clinical practice since publication in 2020 is unknown.

Objective

To describe neonatal RBC transfusion practice in Europe.

Design, Setting, and Participants

This international prospective observational cohort study collected data between September 1, 2022, and August 31, 2023, with a 6-week observation period per center, from 64 NICUs in 22 European countries. Participants included 1143 preterm infants born before 32 weeks of gestation.

Exposure

Admission to the NICU.

Main Outcomes and Measures

Study outcome measures included RBC transfusion prevalence rates, cumulative incidence, indications, pretransfusion hemoglobin (Hb) levels, volumes, and transfusion rates, Hb increment, and adverse effects of RBC transfusion.

Results

A total of 1143 preterm infants were included (641 male [56.1%]; median gestational age at birth, 28 weeks plus 2 days [IQR, 26 weeks plus 2 days to 30 weeks plus 2 days]; median birth weight, 1030 [IQR, 780-1350] g), of whom 396 received 1 or more RBC transfusions, totaling 903 transfusions. Overall RBC transfusion prevalence rate during postnatal days 1 to 28 was 3.4 transfusion days per 100 admission days, with considerable variation across countries, only partly explained by patient mix. By day 28, 36.5% (95% CI, 31.6%-41.5%) of infants had received at least 1 transfusion. Most transfusions were given based on a defined Hb threshold (748 [82.8%]). Hemoglobin levels before transfusions indicated for threshold were below the restrictive thresholds set by ETTNO in 324 of 729 transfusions (44.4%) and TOP in 265 of 729 (36.4%). Conversely, they were between restrictive and liberal thresholds in 352 (48.3%) and 409 (56.1%) transfusions, respectively, and above liberal thresholds in 53 (7.3%) and 55 (7.5%) transfusions, respectively. Most transfusions given based on threshold had volumes of 15 mL/kg (470 of 738 [63.7%]) and were administered over 3 hours (400 of 738 [54.2%]), but there was substantial variation in dose and duration.

Conclusions and Relevance

In this cohort study of very preterm infants, most transfusions indicated for threshold were given for pretransfusion Hb levels above restrictive transfusion thresholds evaluated in recent trials. These results underline the need to optimize practices and for implementation research to support uptake of evidence.