A practical guide to reducing/eliminating red blood cell transfusions in the neonatal intensive care unit.

Red blood cell transfusions can be lifesaving for neonates with severe anemia or acute massive hemorrhage. However, it is imperative to understand that red cell transfusions convey unique and significant risks for neonates. The extremely rare risks of transmitting a viral, bacterial, or other microbial infection, or causing circulatory overload are well known and are part of blood transfusion informed consent. Less well known, and not always part of the consent process, are more common risks of transfusing the smallest and most immature NICU patients; specifically, multiple transfusions may worsen inflammatory conditions (particularly pulmonary inflammation), and in certain subsets are associated with retinopathy of prematurity and neurodevelopmental delay. Instituting non-pharmacological transfusion-avoidance techniques reduces transfusion rates. Pharmacological transfusion-avoidance, specifically erythropoietic stimulating agents, further reduces the risk of needing a transfusion. The protocols described herein constitute an efficient and cost-effective transfusion-avoidance program. Using these protocols, many NICU patients can remain transfusion-free.