Red cell and platelet transfusions in neonates: a population-based study

The future of blood services amid a tight balance between the supply and demand of blood products: Perspectives from the ISBT Young Professional Council

BACKGROUND AND OBJECTIVES

Blood services manage the increasingly tight balance between the supply and demand of blood products, and their role in health research is expanding. This review explores the themes that may define the future of blood banking.

MATERIALS AND METHODS

We reviewed the PubMed database for articles on emerging/new blood-derived products and the utilization of blood donors in health research.

RESULTS

In high-income countries (HICs), blood services may consider offering these products: whole blood, cold-stored platelets, synthetic blood components, convalescent plasma, lyophilized plasma and cryopreserved/lyophilized platelets. Many low- and middle-income countries (LMICs) aim to establish a pool of volunteer, non-remunerated blood donors and wean themselves off family replacement donors; and many HICs are relaxing the deferral criteria targeting racial and sexual minorities. Blood services in HICs could achieve plasma self-sufficiency by building plasma-dedicated centres, in collaboration with the private sector. Lastly, blood services should expand their involvement in health research by establishing donor cohorts, conducting serosurveys, studying non-infectious diseases and participating in clinical trials.

CONCLUSION

This article provides a vision of the future for blood services. The introduction of some of these changes will be slower in LMICs, where addressing key operational challenges will likely be prioritized.

Fetoscopic Laser Ablation of Type II Vasa Previa: A Cost Benefit Analysis

OBJECTIVE

 We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard management (SM).

STUDY DESIGN

 A decision analytic model and cost-benefit analysis from a health care perspective were performed. The population included patients with type II vasa previa at approximately 32 weeks. SM entailed 32-week antepartum admission and cesarean at approximately 35 weeks. FLS referral included consultation and possible laser surgery at 32 weeks for willing/eligible candidates. Successful laser surgery allowed the possibility of term vaginal delivery. Outcomes included antepartum admission, preterm birth, cesarean, neonatal transfusion, and death. Sensitivity analyses were performed.

RESULTS

 In base case analysis, FLS referral was cost saving compared with SM (total cost per patient $65,717.10 vs. 71,628.16). FLS referrals yielded fewer antepartum admissions, cesareans, premature births, neonatal transfusions, and deaths. Eligible referred patients choosing FLS incurred a total cost of $41,702.46, a >40% decrease compared with SM. FLS referral was cost saving in all one-way sensitivity analyses except when antepartum admission costs were low. In threshold analyses, FLS referral was cost saving unless laser surgery cost was >$39,892 (2.75x expected cost), antepartum admission cost for monitoring of vasa previa or ruptured membranes was <$7,455, <11% patients were eligible for laser surgery, and when <12% of eligible patients chose laser surgery. In two-way sensitivity analysis, FLS referral was cost saving except at very high laser surgery costs and extremely low antepartum admission costs.

CONCLUSION

 Referral for FLS for type II vasa previa was cost saving and improved outcomes compared with SM, despite upfront costs, fetoscopy-related risks, and many patients being ineligible or not opting for surgery after referral.

KEY POINTS

· Vasa previa rupture may lead to fetal exsanguination and death.. · Late preterm cesarean is common practice for prenatally diagnosed vasa previa.. · Successful fetoscopic laser ablation for type II vasa previa has been described.. · Laser ablation of vasa previa allows for a safe-term vaginal delivery.. · Referral for laser surgery is cost saving and is associated with improved outcomes..

Effects of Freshly Irradiated vs Irradiated and Stored Red Blood Cell Transfusion on Cerebral Oxygenation in Preterm Infants: A Randomized Clinical Trial

IMPORTANCE

Gamma irradiation of leukoreduced red blood cells (RBCs) prevents transfusion-associated graft-vs-host disease but also exacerbates storage lesion formation in RBCs. It is unknown whether freshly irradiated RBCs are more efficacious than irradiated and stored RBCs in preterm infants with high transfusion requirements.

OBJECTIVE

To examine whether transfusion of freshly irradiated vs irradiated and stored RBC components improves cerebral oxygen delivery in preterm infants with anemia.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, double-blinded, proof-of-concept randomized clinical trial was conducted at the neonatal intensive care unit of Wellington Regional Hospital in Wellington, New Zealand, between December 1, 2017, and November 30, 2018. Participants were preterm infants (<34 weeks' gestation at birth) who were at least 14 days of age and had anemia. Participants underwent nonurgent transfusions, and these episodes were randomized to the intervention group (in which the infants received a transfusion of RBCs that were freshly irradiated on the day of transfusion) or control group (in which the infants received a transfusion of RBCs that were irradiated and stored for up to 14 days). Data were analyzed using the evaluable population approach.

INTERVENTION

Transfusion of freshly irradiated RBCs.

MAIN OUTCOMES AND MEASURES

The prespecified primary outcome was the change in cerebral regional oxygen saturation (crSO2) from baseline (immediately before) to immediately after the transfusion. The prespecified secondary outcomes were the change in cerebral fractional tissue oxygen extraction (cFTOE) at different time points (immediately after, 24 hours after, and 120 hours or 5 days after transfusion). Outcomes were measured by blinded clinicians using near-infrared spectroscopy. A covariate-adjusted linear mixed model was used to quantify mean treatment effects and account for multiple transfusions in some infants.

RESULTS

A total of 42 infants (mean [SD] gestational age, 26 [10] weeks and 3 days; 29 [69%] boys) were enrolled in the trial and underwent 64 transfusion episodes, which were randomized to the intervention (n = 31) or control (n = 33) group. Compared with infants in the control group, those in the intervention group showed a covariate-adjusted mean increase in crSO2 (2.0 percentage points; 95% CI, 1.2-2.8 percentage points) and a mean decrease in cFTOE (0.02; 95% CI, 0.01-0.04) immediately after transfusion. These differences were sustained up to 120 hours or 5 days after transfusion. There were negligible mean changes in crSO2 or cFTOE in infants in the control group at any of the follow-up time points.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that transfusion of freshly irradiated RBCs conferred a small advantage in cerebral oxygenation for at least 5 days after transfusion compared with transfusion of irradiated and stored RBC components. On-demand irradiation of RBC components may be considered to optimize oxygen delivery in the recipient, but this physiological finding requires further research.

TRIAL REGISTRATION

ANZCTR Identifier: ACTRN12617001581358.

Anemia of prematurity: how low is too low?

Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.

Embedding best transfusion practice and blood management in neonatal intensive care

Background

Transfusion is a common procedure for neonates receiving intensive care management. Recognising a paucity of patient blood management (PBM) programmes in neonates, we aimed to embed blood management and best transfusion principles in the neonatal intensive care unit (NICU) by aligning local policies, providing targeted education and partnering with parents.

Methods

Practice-based evidence for clinical practice improvement (PBE-CPI) methodology was used. Previous hospital accreditation audits were reviewed and a neonate-specific transfusion audit was developed. Audit was performed at baseline and repeated following the intervention period. NICU clinicians received targeted education in obtaining informed consent, prescription and safe administration of blood components during a ‘Blood Month’ awareness period. A neonate-specific parent handout about transfusion was developed in partnership with parents. A pilot video demonstrating a shared consent discussion was also developed to assist in the consent process. Parents’ knowledge, concerns and feedback regarding transfusion practice was sought at baseline (survey) and on project completion (experience trackers).

Results

Neonate-specific baseline transfusion audit showed inconsistent consent, monitoring and documentation processes in neonatal transfusions. Post-targeted education audit showed improvement in these parameters. The targeted PBM and transfusion-related education delivered during ‘Blood Month’ was well-received by staff. Parents’ feedback about the NICU transfusion consenting process was consistently positive. NICU medical and nursing clinicians (n=25) surveyed agreed that the parent handout was well set out, easy to understand and recommended that it be used to complement practice.

Conclusion

PBE-CPI tools aligned with Australian PBM guidelines for clinicians and parents were well-accepted by clinical stakeholders and were associated with practice improvement in PBM awareness and transfusion consent processes. This PBE-CPI project developed NICU-specific consent information, not previously available, by partnering with parents to ensure quality of care in transfusion practice. Adoption of this also helps to meet accreditation for Australian Blood Management Standards. These strategies and tools translate readily into other NICUs to embed and support best PBM and transfusion practice.

Allogeneic cord blood transfusions prevent fetal haemoglobin depletion in preterm neonates. Results of the CB-TrIP study

Repeated red blood cell (RBC) transfusions in preterm neonates are associated with poor outcome and increased risk for prematurity-associated diseases. RBC transfusions cause the progressive replacement of fetal haemoglobin (HbF) by adult haemoglobin (HbA). We monitored HbF levels in 25 preterm neonates until 36 weeks of post-menstrual age (PMA); patients received RBC units from allogeneic cord blood (cord-RBCs) or from adult donors (adult-RBCs), depending on whether cord-RBCs were available. Primary outcome was HbF level at PMA of 32 weeks. Twenty-three neonates survived until this age: 14 received no transfusions, two only cord-RBCs, three only adult-RBCs and four both RBC types. HbF levels in neonates transfused with cord-RBCs were significantly higher than in neonates receiving adult-RBCs (P < 0·0001) or both RBC types (P < 0·0001). Superimposable results were obtained at PMA of 36 weeks. Every adult-RBCs transfusion increased the risk for an HbF in the lowest quartile by about 10-fold, whereas this effect was not evident if combined adult- and cord-RBCs were evaluated. Overall, these data show that transfusing cord-RBCs can limit the HbF depletion caused by conventional RBC transfusions. Transfusing cord blood warrants investigation in randomised trials as a strategy to mitigate the severity of retinopathy of prematurity (NCT03764813).

Severe neonatal anemia increases intestinal permeability by disrupting epithelial adherens junctions

Anemia is a frequent diagnosis in critically ill infants, but the clinical implications of severe anemia in these patients remain unclear. In this study, we examined preweaned mice to investigate the effects of severe anemia during early infancy on gut mucosal permeability. C57BL/6 mice were subjected to timed phlebotomy between postnatal days (P) 2-10 to induce severe anemia (hematocrits 20%-24%), and intestinal permeability was tracked longitudinally between P10 and P20 as intestine-to-plasma translocation of enteral macromolecules and bacterial translocation. Epithelial junctions were evaluated by electron microscopy, polymerase chain reactions, immunohistochemistry, and/or enzyme immunoassays on intestinal tissues, Caco-2 intestinal epithelial-like cells, and colonic organoids. Preweaned mouse pups showed an age-related susceptibility to severe anemia, with increased intestinal permeability to enteral macromolecules (dextran, ovalbumin, β-lactoglobulin) and luminal bacteria. Electron micrographs showed increased paracellular permeability and ultrastructural abnormalities of the adherens junctions. These findings were explained by the loss of E-cadherin in epithelial cells, which was caused by destabilization of the E-cadherin (Cdh1) mRNA because of microRNA let-7e-5p binding to the 3'-untranslated region. Severe anemia resulted in a disproportionate and persistent increase in intestinal permeability in preweaned mice because of the disruption of epithelial adherens junctions. These changes are mediated via microRNA let-7e-mediated depletion of Cdh1 mRNA.NEW & NOTEWORTHY This research article shows that newborn infants with severe anemia show an age-related susceptibility to developing increased intestinal permeability to ingested macromolecules. This abnormal permeability develops because of abnormalities in intestinal epithelial junctions caused by a deficiency of the molecule E-cadherin in epithelial cells. The deficiency of E-cadherin is caused by destabilization of its mRNA precursor because of increased expression and binding of another molecule, the microRNA let-7e-5p, to the E-cadherin mRNA.

Management of anaemia in pre-term infants

Pre-term infants have one of the highest transfusion requirements within the hospital-setting. The vast majority of blood transfusions performed in Neonatal Intensive Care Units (NICUs) are for medically stable pre-term infants with anaemia of prematurity, with the aim of improving oxygen delivery to the vital organs during the crucial phase of growth and development. However, despite the frequency of transfusion in this population, the potential benefits and harms of 'top up' transfusion are not fully understood, leading to practice variation between clinicians, institutions and countries. Significant advances have been made in the prevention of anaemia of prematurity, with recent emphasis on optimising infants' circulatory volume at birth via placental transfusion and preserving infants' own blood volume through innovative minimal sampling techniques. More research is urgently needed to establish optimal transfusion thresholds for these high-risk pre-term infants, for whom benefits as well as adverse outcomes may have consequences that extend for decades throughout the recipients' life-course. In this review, we will discuss some of the consensus and controversies regarding optimal management of anaemia in pre-term infants and highlight potential areas for future research.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study

AIM

Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions.

METHODS

Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated.

RESULTS

Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group.

CONCLUSION

Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Association between anemia and postoperative complications in infants undergoing pyloromyotomy

BACKGROUND

Although preoperative anemia has been suggested to predict postsurgical morbidity and mortality among infants <1 year of age, the data were drawn from heterogeneous patient cohorts including severely ill infants undergoing complex, high-risk procedures. We aimed to determine whether untreated preoperative anemia was associated with increased risk of postoperative complications in infants <1 year of age who underwent pyloromyotomy, a common and relatively simple surgery.

METHODS

Infants <1 year of age undergoing pyloromyotomy were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program-Pediatric database. Preoperative anemia was defined as a hematocrit ≤40% for infants 0-30 days of age and ≤30% for infants more than 30 days of age. Patients who received pre- or postoperative blood transfusions were excluded.

RESULTS

We identified 2948 patients who met our inclusion criteria, of whom 843 were anemic (29%). The overall rate of complications in this cohort was 6%. The most common postoperative complications were readmission (97 cases), surgical site infection (43), reoperation (39), prolonged hospital stay (24), urinary tract infection (3), 30-day mortality (3) and cardiac arrest (2). We found no differences in the incidence of complications in anemic versus nonanemic patients on bivariate analysis or multivariable logistic regression (adjusted odds ratio = 1.2; 95% confidence interval: 0.8-1.7; P = 0.319).

CONCLUSIONS

In relatively healthy infants undergoing pyloromyotomy, untreated preoperative anemia was not associated with postoperative compilations and should not be considered a significant risk factor. Level of evidence III.

Effect of Umbilical Cord Blood Sampling versus Admission Blood Sampling on Requirement of Blood Transfusion in Extremely Preterm Infants: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of blood sampling from the placental end of the umbilical cord compared with initial blood sampling from neonates, on the need for first packed red blood cell transfusion in extremely preterm infants. We hypothesized that cord blood sampling could delay the time to first blood transfusion.

STUDY DESIGN

In this single-center, assessor blind, randomized controlled trial, we included extremely low birth weight neonates <28 weeks of gestational age at birth. Five milliliter of blood for initial laboratory investigations was collected either from the placental end of the umbilical cord (study group) or from the neonate upon neonatal intensive care unit admission (control group). Both groups received similar anemia prevention strategies. The primary outcome was the time (in days) to the first packed red blood cell transfusion, and was compared using survival analysis.

RESULTS

Eighty neonates were enrolled. The time to first transfusion was significantly delayed in the cord sampling group (30 vs 14 days, hazard ratio: 0.44, [95% CI 0.27-0.72], P < .001). Fewer neonates in the cord sampling group were transfused in the first 28 days of life (30% vs 75%, P < .001). Overall transfusion requirements and other clinical outcomes were similar in the groups.

CONCLUSIONS

Initial blood sampling from placental end of umbilical cord, when combined with anemia prevention strategies, significantly prolonged the time to first transfusion and reduced the need for early transfusions among extremely premature neonates.

TRIAL REGISTRATION

Ctri.nic.in/ (CTRI/2017/04/008320).

Turkish Neonatal Society guideline on the transfusion principles in newborns

Blood transfusion can be defined as a life-saving procedure in neonates, especially in premature and surgical infants. The indications, threshold hemoglobin, and platelet levels for red cell, platelet, and plasma transfusions in neonates vary among centers and the evidence-based data for possible adverse effects, preterm morbidities, mortality, and neuro-developmental problems associated with transfusions are not clear yet. Herein, we aim to present the transfusion guideline designed to be used in neonatal intensive care units in our country, summarizing clinical findings and threshold levels for red cell, platelet, and plasma transfusions in addition to important practical points of transfusions according to a literature review.

Elevated brain oxygen extraction fraction in preterm newborns with anemia measured using noninvasive MRI

OBJECTIVE

To test the hypothesis that cerebral oxygen extraction fraction (OEF) is elevated and inversely related to hematocrit level in anemic former very-low-birth-weight infants near term.

STUDY DESIGN

Prospective study of non-sedated preterm infants (post-menstrual age = 36 ± 2 weeks) over a range of hematocrits (0.23-0.49). Anatomical (T₁-W, T₂-W, and diffusion-weighted), cerebral blood flow (CBF), and OEF 3-T MRI were utilized. Statistical analysis included Spearman's rank-order correlation testing between study variables and intraclass correlation coefficients (ICC) calculated between consecutively acquired OEF scans.

RESULTS

Consecutive OEF measurements showed moderate-to-good agreement (ICC = 0.71; 95% CI = 0.40-0.87). OEF increased with worsening anemia (ρ = -0.58; p = 0.005), and OEF and basal ganglia CBF were positively correlated (ρ = 0.49; p = 0.023).

CONCLUSION

Noninvasive OEF MRI has moderate-to-good repeatability in non-sedated former preterm infants nearing term-equivalent age. Strong correlation of elevated OEF with anemia suggests hemodynamic compensation for anemia and could establish OEF as a useful biomarker of transfusion threshold for preterm infants.

Vasa previa screening strategies: decision and cost-effectiveness analysis

OBJECTIVE

To perform a decision and cost-effectiveness analysis comparing four screening strategies for the antenatal diagnosis of vasa previa in singleton pregnancies.

METHODS

A decision-analytic model was constructed comparing vasa previa screening strategies. Published probabilities and costs were applied to four transvaginal screening scenarios that were carried out at the time of mid-trimester ultrasound: no screening, ultrasound-indicated screening, screening only pregnancies conceived by in-vitro fertilization (IVF) and universal screening. Ultrasound-indicated screening was defined as performing transvaginal ultrasound at the time of the routine anatomy ultrasound scan in response to one of the following sonographic findings associated with an increased risk of vasa previa: low-lying placenta, marginal or velamentous cord insertion or bilobed or succenturiate lobed placenta. The primary outcome was cost per quality-adjusted life year (QALY) in US$. The analysis was performed from a healthcare system perspective with a willingness-to-pay threshold of $100 000 per QALY selected. One-way and multivariate sensitivity analysis (Monte-Carlo simulation) was performed.

RESULTS

This decision-analytic model demonstrated that screening pregnancies conceived by IVF was the most cost-effective strategy, with an incremental cost effectiveness ratio (ICER) of $29186.50/QALY. Ultrasound-indicated screening was the second most cost-effective, with an ICER of $56096.77/QALY. These data were robust to all one-way and multivariate sensitivity analyses performed.

CONCLUSIONS

Within the baseline assumptions, transvaginal ultrasound screening for vasa previa appears to be most cost-effective when performed among IVF pregnancies. However, both IVF and ultrasound-indicated screening strategies fall within contemporary willingness-to-pay thresholds, suggesting that both strategies may be appropriate to apply in clinical practice. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Impact of Blood Donor Sex on Transfusion-Related Outcomes in Preterm Infants

OBJECTIVE

Explore the role of red blood cell donor sex on preterm infant neonatal outcomes.

STUDY DESIGN

In a retrospective, exploratory, cohort study, the hospital blood bank database was queried for units of blood released to neonatal intensive care unit patients in 2009-2010. The state blood center provided donor sex, and a department database provided neonatal characteristics and morbidities. Comparisons were made for 2 groups: those who ever received female blood and those who did not.

RESULTS

Among 462 infants <32 weeks of gestation, 190 (41%) received >1 blood transfusion. In univariate analyses, compared with infants who received only male blood, infants who received female donor blood had higher rates of bronchopulmonary dysplasia (38% vs 22%; P = .03), spontaneous intestinal perforation/necrotizing enterocolitis (17% vs 6%; P = .04), and death or any morbidity (60% vs 38%; P < .01), respectively. In adjusted analyses, female blood was associated with any morbidity (P = .0251) and 21 days longer hospitalization (P = .0098). After adding total number transfusions to the model, only an increased number of transfusions was associated with bronchopulmonary dysplasia (P = .0009), any morbidity (P = .0001), and length of stay (P = .0001). In subset regressions comparing exclusively female donor blood with male donor blood, there was a significant interaction of female donor blood and number of transfusions for any morbidity (OR 2.6 95% CI 1.2-5.7, P = .01).

CONCLUSIONS

Preliminary findings suggest that female donor blood was associated with preterm vulnerability to neonatal morbidities.

Patient blood management, what does this actually mean for neonates and infants?

Patient blood management (PBM) refers to an evidence-based package of care that aims to improve patient outcomes by optimal use of transfusion therapy, including managing anaemia, preventing blood loss and improving anaemia tolerance in surgical and other patients who may need transfusion. In adults, PBM programmes are well established, yet the definition and implementation of PBM in neonates and children lags behind. Neonates and infants are frequently transfused, yet they are often under-represented in transfusion trials. Adult PBM programmes may not be directly applicable to these populations. We review the literature in neonatal (and applicable paediatric) transfusion medicine and propose specific neonatal PBM definitions and elements.

Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study

BACKGROUND

Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data.

METHODS

Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed.

RESULTS

Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)).

CONCLUSIONS

Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.