Newborns Getting Preoperative Blood Transfusions Have More Complications

Blood transfusions in the neonatal patient population are common, but there are no established guidelines regarding transfusion thresholds. Little is known about postoperative outcomes in neonates who receive preoperative blood transfusions (PBTs).

Transfusion practices in neonatal intensive care units (ICUs) remain highly variable despite several randomized trials showing no harm with a restrictive transfusion strategy in babies compared with a liberal one. It's not uncommon for anemic newborns to receive transfusions prior to surgery as a precaution.

Medical scientists at the Alfred I. duPont Hospital for Children (Wilmington, DE, USA) and their colleagues identified a total of 12,184 neonates, of whom 1,209 (9.9%) received a PBT, all neonates who underwent surgery. Mortality and composite morbidity (defined as any postoperative complication) in neonates who received a PBT within 48 hours of surgery were compared with that in neonates who did not receive a transfusion.

The team reported that the incidence of 30-day mortality (16.8% versus 2.6%) and morbidity (46.2% versus 16.2%) put neonates who received blood transfusion within 48 hours of surgery at a disadvantage compared with peers not getting transfusion. Blood transfusion remained associated with worse postoperative outcomes after multivariable adjustment and propensity-score matching.

Specific postoperative complications that occurred more frequently in the transfusion group included infection, bleeding requiring transfusion, reintubation, reoperation, and hospital stay beyond 30 days. However, babies who did not receive transfusion had more readmissions within 30 days of surgery. There appeared to be a stronger relationship between mortality and morbidity and blood transfusion with rising preoperative hematocrit (up to 35%), though this finding did not reach statistical significance for interaction.

The authors concluded that it is likely that there is a tipping point or range in which the risks associated with anemia outweigh the risks associated with blood transfusion. For infants with significant anemia, it is plausible that the benefits of a blood transfusion, such as increased oxygen delivery, outweigh the associated risks (i.e., transfusion-related immunomodulation and a proinflammatory state), but as the anemia becomes less severe, the harm of a blood transfusion begins to outweigh the benefit. The study was published on October 1, 2020 in the journal Pediatrics.

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Alfred I. duPont Hospital for Children