673 - Less is More-Transition to Lower Thresholds for packed Red Blood Cells (pRBCs) to Reduce Transfusions in Preterm Neonates <35 Weeks

Publication Number: 673.5770

Sheetal Chepuri, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Kavya Rao, Oishei Childrens Hospital - University at Buffalo, Buffalo, NY, United States; Praveen Chandrasekharan, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY, United States; Valerie Elberson, John R. Oishei Children's Hospital, Buffalo, NY, United States

Background: The threshold for packed Red Blood Cell (pRBC) transfusion in preterm neonates has long been controversial. Most recently, the Transfusion of Prematurity (TOP) trial showed no increase in the risk of death or neurodevelopmental impairment in the lower-threshold transfusion group (Kirpalani, 2020). With more research emerging that transfusions may contribute to morbidities, such as bronchopulmonary dysplasia (BPD) (Bahr, 2024), centers are moving towards lower thresholds to decrease transfusions.

Objective: We intended to transition to a lower threshold transfusion protocol and reduce pRBC transfusions in infants < 35 weeks by at least 20 percent.

Design/Methods: In Dec. of 2023, we performed a literature review and began compiling baseline data. The literature and a revised protocol were presented to the faculty in Jan. 2024. The protocol was disseminated along with provider education in Feb. 2024. A copy of the new protocol was placed in the provider workrooms to reinforce the thresholds and availability in the EMR. In our unit, routine labs are obtained in the early morning, and transfusions are administered prior to daytime rounds. An emphasis was placed on making transfusion decisions primarily by the day team, as there were often differences in opinion and protocol interpretation. The staff was educated about the potential negative effects of transfusions. Iron optimization was reviewed, and patients were evaluated weekly through collaboration with nutrition and pharmacy. A focus was also placed on optimizing birth hematocrit through a grand round with obstetrics discussing the benefits of delayed cord clamping and cord milking Fig 1.

Results: Baseline demographics including gestational age, birth weight, and sex were similar between the two groups Fig 2. Transfusions were calculated per 1000 patient days with a baseline rate of 34.7/1000 patient days for infants < 35 weeks. Our target was to reduce the number of transfusions by 20 percent to 27.8/1000 patient days. By the end of data collection, we had reduced our number of transfusions to 25.2/1000 patient days for 2024 ( < 20%) Fig. 3. Balancing measures of severe intraventricular hemorrhage (grade 3 or 4), stage 2 necrotizing enterocolitis or higher, and mortality showed no difference Fig. 2.

Conclusion(s): Lowering thresholds for pRBC transfusion was feasible at our center, and we achieved our target reduction by 20%. Potential patient benefits include less blood product usage, fewer adverse effects, including stopping feeds during transfusion and using diuretics, and cost savings. We anticipate evaluating protocol adherence for future directions.

Transition to Lower Thresholds for packed Red Blood Cell (pRBC) to Reduce Transfusions in Preterm Neonates <35 Weeks
Slide1.jpegFig 1. Key Driver Diagram

Demographics and Balancing Measures
Slide1.jpegFig 2. No significant differences between the baseline period and the intervention period.

PRBC Transfusions per 1000 Patient Days in Infants < 35 weeks GA
Slide1.jpegFig 3. PRBC Transfusions/1000 Patient Days in Infants < 35 weeks GA per month. Baseline period 34.7/1000 patient days for infants less than 35 weeks. Target 27.8/1000. By the end of the data collection period, 25.2/1000 patient days for 2024.