Survey of transfusion practices in preterm infants in Europe

Abstract

Background: Preterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in Europe and to compare our findings to three recent randomised controlled trials to understand how clinical practice relates to the trial data.

Methods: From October to December 2020, we performed an online survey among 597 neonatal intensive care units (NICUs) caring for infants with a gestational age (GA) of <32 weeks in 18 European countries.

Results: Responses from 343 NICUs (response rate: 57%) are presented and showed substantial variation in clinical practice. For RBC transfusions, 70% of NICUs transfused at thresholds above the restrictive thresholds tested in the recent trials and 22% below the restrictive thresholds. For platelet transfusions, 57% of NICUs transfused at platelet count thresholds above 25×10⁹/L in non-bleeding infants of GA of <28 weeks, while the 25×10⁹/L threshold was associated with a lower risk of harm in a recent trial. FFP transfusions were administered for coagulopathy without active bleeding in 39% and for hypotension in 25% of NICUs. Transfusion volume, duration and rate varied by factors up to several folds between NICUs.

Conclusions: Transfusion thresholds and aspects of administration vary widely across European NICUs. In general, transfusion thresholds used tend to be more liberal compared with data from recent trials supporting the use of more restrictive thresholds. Further research is needed to identify the barriers and enablers to incorporation of recent trial findings into neonatal transfusion practice.

Keywords: child health; data collection; epidemiology; healthcare disparities; neonatology.

Figure 1

(A) Violin plots of haemoglobin-based RBC transfusion thresholds for different postnatal age and respiratory support levels in infants born at 30%=infants on 30% oxygen by non-invasive respiratory support (including continuous positive airway pressure, biphasic intermittent positive airway pressure (synchronised or unsynchronised) and nasal high flow). Ventilated=infants who are intubated and ventilated. The grey boxes highlight the values between the restrictive and liberal ETTNO/TOP thresholds (online supplemental table S1). Cochrane SR refers to the restrictive thresholds of previous trials, summarised in a Cochrane systematic review by Whyte et al. Number of datapoints per violin plot: 325, 323, 324, 324, 326, 327, 326, 325, 324, 327, 327, 327, 324, 325 and 326 (from left to right). Violin plots are a combination of a boxplot (showing median and IQRs) with a kernel density plot (showing the distribution of the data). The wider the plot, the more NICUs selected this threshold. (B) 100% stacked bar chart showing for each clinical scenario the proportion of the reported transfusion thresholds (from top to bottom) that were above the liberal ETTNO/TOP threshold, at the liberal ETTNO/TOP threshold, between the liberal and restrictive ETTNO/TOP threshold, at the restrictive ETTNO/TOP threshold or below the restrictive ETTNO/TOP threshold. ETTNO, Effects of Transfusion Thresholds on Neurocognitive Outcomes of Extremely Low-Birth-Weight Infants; NICU, neonatal intensive care unit; RBC, red blood cell; TOP, Transfusion of Prematures.

Figure 2

Violin plots of platelet count transfusion thresholds for different clinical scenarios. Datapoints per violin plot: 332, 297, 316, 311, 329, 333, 297, 317, 311 and 331, from left to right. Violin plots are a combination of a boxplot (showing median and IQRs) with a kernel density plot (showing the distribution of the data). The wider the plot, the more NICUs selected this threshold. MATISSE, Management of Thrombocytopenia in Special Subgroup.

Figure 3

Transfusion volume, duration and rates for RBC, platelet and plasma transfusions. Bubble size and values within larger bubbles represent the number and percentage of NICUs. Platelet transfusion volume outlier at 4 mL/kg represents one NICU providing hyperconcentrated platelet transfusions. Datapoints for RBC, platelet and FFP volumes: 335, 335 and 336. Datapoints for RBC, platelet and FFP durations: 333, 330 and 335. FFP, fresh frozen plasma; NICU, neonatal intensive care unit; RBC, red blood cell.