151 - Organ Dysfunction as a Novel Adjunct for Red Blood Cell (RBC) Transfusion Decisions in Extremely Preterm and Extremely Low Birth Weight Infants

Publication Number: 2145.151

Elizabeth P. Crowe, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Robert Barrett, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Jenn Jones, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Dominique Tran, Johns Hopkins All Children's Hospital, St Petersburg, FL, United States; Michelle Hojnicki, Johns Hopkins All Children's Hospital, Palmetto, FL, United States; James L. Wynn, University of Florida College of Medicine, Gainesville, FL, United States; Cassandra Josephson, Medtronic, St. Petersburg, FL, United States; Khyzer B. Aziz, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Background: Current transfusion decision-making in extremely low birth weight (ELBW) infants primarily relies on hemoglobin, an approach that inadequately captures clinical complexity and poorly predicts transfusion needs. This strategy exposes infants to transfusion-related risks and necessitates frequent phlebotomy, paradoxically increasing transfusion requirements. The neonatal Sequential Organ Failure Assessment (nSOFA) score offers dynamic illness severity assessment encompassing cardiovascular, respiratory, and hematologic function but remains underutilized for optimizing transfusion.

Objective: To evaluate nSOFA as a predictor of red blood cell (RBC) transfusion in ELBW infants and compare its performance to hemoglobin and phlebotomy losses.

Design/Methods: We conducted a retrospective, multicenter cohort study of ELBW infants ( < 1000g, < 29 weeks gestational age (GA)) in four neonatal intensive care units from 2016-2025. The nSOFA score (range 0-15) was calculated hourly to measure high-resolution organ dysfunction trajectory. An adjusted receiver operator characteristic area under curve (AUC) analysis was used to compare hemoglobin concentration, nSOFA score, and cumulative weight adjusted phlebotomy loss for predicting RBC transfusion.

Results: Among 526 infants (49% male, median GA 25 weeks, birth weight 750 grams), 90% (n=476) were transfused RBCs (median [interquartile range] total volume 74 [40-127] mL/kg/patient). Transfused infants sustained greater cumulative blood loss from phlebotomy 82.3 [56.7-125.5] mL/kg vs. 38.2 [22.1-50.9] mL/kg in non-transfused infants, p< 0.001 during admission. Hemoglobin was lower in infants transfused over the first two weeks of life and failed to discriminate between transfused and non-transfused groups thereafter (Figure, left panel). Organ dysfunction trajectories diverged by transfusion status (Figure, right panel). Significantly greater cumulative nSOFA scores were observed in transfused infants by day 3 of life. nSOFA (mean AUC 0.720) was superior to hemoglobin (mean AUC 0.554) as a predictor of RBC transfusion. Phlebotomy loss (mean AUC 0.740) was superior to either hemoglobin or nSOFA as single predictors; however, the addition of nSOFA and hemoglobin (mean AUC 0.780) outperformed phlebotomy loss alone.

Conclusion(s): This multicenter study comprising greater than 1.2 million patient-level measures over 7,628 patient-weeks provides the first evidence supporting the utility of an organ dysfunction score as an adjunct to hemoglobin for precision-guided transfusion management in ELBW preterm infants.

Hemoglobin Concentration and Organ Dysfunction Trajectories by RBC Transfusion Status.
Left: Hemoglobin concentration in transfused and non-transfused extremely low birth weight (ELBW) infants over the first six weeks of life. Right: Cumulative nSOFA scores in transfused and non-transfused ELBW infants over the first six weeks of life.