150 - Implementing Novel Red Blood Cell Transfusion Guidelines Reduces Unnecessary Transfusions in Neonates

Publication Number: 2144.150

Rachel Schwemberger, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, United States; Yaseen Jamal, Stanford University School of Medicine, Stanford, CA, United States; Furkan Yigitbilek, Stanford University School of Medicine, Sacramento, CA, United States; Danielle Wetzel, Lucile Packard Children's Hospital Stanford, El Granada, CA, United States; Alexis Davis, Stanford University School of Medicine, Palo Alto, CA, United States; Mrigender S. Virk, Stanford University School of Medicine, Stanford, CA, United States; Hua Shan, Stanford University, Palo Alto, CA, United States; Valerie Y.. Chock, Stanford University School of Medicine, Palo Alto, CA, United States

Background: Variation in red blood cell transfusion practices remains a challenge in the neonatal intensive care unit (NICU). Restrictive transfusion guidelines have not been associated with adverse outcomes, and monitoring for adequate cerebral tissue saturation using near-infrared spectroscopy (NIRS) may provide further reassurance in adhering to restrictive transfusion guidelines.

Objective: We evaluated the impact of implementing innovative restrictive transfusion guidelines that incorporate hemoglobin level, clinical criteria, and cerebral saturations (Csat).

Design/Methods: Implementation of transfusion guidelines included a NICU-wide educational initiative and development of a best practice alert (BPA) integrated into the electronic medical record that utilizes a hemoglobin threshold of < 10 g/dL, respiratory support criteria, and a Csat threshold of ≤50% (Fig. 1). The impact of these guidelines on transfusion metrics and clinical outcomes before and 6-months after implementation was investigated. Statistical testing (Mann-Whitney, Fisher's Exact, t-test) was performed as appropriate using a one-tailed significance threshold of p < 0.05.

Results: Altogether, 182 patients were included across a 28 month period, with 97 before and 85 post-implementation. Following implementation of transfusion guidelines, we found a significant decrease in mean transfusions per patient (3.85 to 3.05), representing a 20.8% reduction (p=0.03). Additionally, mean pre-transfusion hemoglobin levels declined from 10.5 g/dL to 10.0 g/dL (p=0.03), and the proportion of transfusions administered at hemoglobin levels exceeding 10 g/dL also significantly decreased (38.4% to 29.6%; p=0.02, Fig. 2). On a per-patient basis, mean number of transfusions exceeding both hemoglobin and Csat criteria decreased from 1.10 to 0.54 (p < 0.01). No significant differences in demographics or pre-transfusion vital signs were found. Despite these more restrictive transfusion practices, there were no significant increases in adverse outcomes including mortality, sepsis, retinopathy of prematurity, intraventricular hemorrhage, patent ductus arteriosus, or necrotizing enterocolitis (Table 1).

Conclusion(s): Implementation of restrictive transfusion guidelines significantly reduced red blood cell transfusions without compromising clinical outcomes. This approach demonstrates that evidence-based hemoglobin threshold guidelines augmented by clinical characteristics and physiologic NIRS monitoring can effectively limit the risks of blood product exposure without adverse outcomes in vulnerable neonatal populations.

Figure 1
Figure 1: Novel red blood cell transfusion guidelines implemented as a NICU-wide educational initiative and as a best practice alert (BPA) integrated into the electronic medical record.

Figure 2
Figure 2: A. Mean number of transfusions per patient decreased from the pre/transition period to post-implementation of transfusion guidelines. B. Proportion of transfusions administered at hemoglobin levels exceeding 10 g/dL decreased from the pre/transition period to post-implementation of transfusion guidelines.

Table 1
Table 1: Clinical outcomes during pre/transition vs. post implementation of transfusion guidelines. Abbreviations: Intraventricular hemorrhage (IVH), Necrotizing enterocolitis (NEC), Retinopathy of prematurity (ROP), Patent Ductus Arteriosus (PDA).