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TRANSFUSION-FREE PROGRAM
Guidelines and Recommendations

To maximize patient outcome in a transfusion-free practice.

Patients include all infants admitted to the NICU (with a special emphasis on those babies with a birth weight of less than 1000 grams).

I. Placental blood flow to the infant should be maximized prior to clamping the umbilical cord.
Cord blood should be used for all appropriate initial tests.

II. Reduce iatrogenic blood loss.

A. Perform no unnecessary laboratory tests. No routine or standardized orders should be utilized for
blood work.

B. Point of care microsampling.
C. Non-invasive oxygen and carbon dioxide monitoring (continuous oximetry / TCM).
D. Inline blood gas monitors.

III. Minimize hemorrhagic blood loss.

A. All necessary procedures should be performed with an emphasis on using techniques to avoid blood loss.
B. Ensure appropriate hemostasis with cauterization, sutures, or umbilical ties.
C. Avoid medications or situations associated with an increased likelihood of bleeding. (i.e. indomethacin and / or steroids can lead to gastritis. Bladder catheterization is associated with hematuria).
D. Routine use of ranitidine.
E. Twice weekly vitamin K.
F. Avoid significant hypertension and / or hypotension.
G. Surgical procedures should be performed only by the most experienced surgeons committed to bloodless surgery.

IV. Erythropoietin and iron use.

A. Erythropoietin (200 units / kg/day) should be used from days 3 though 42 in appropriately
selected patients. When using Epogen, iron dextran (1mg/kg/day) should be given in the TPN.
When the infant has been advanced to at least 60cc/kg/day of enteral feedings, intravenous iron
should be discontinued and oral iron (1 mg/kg/day) started.
B. Vitamin E (25 IU/kg/day divided dose BID) should be started when the infant is tolerating
60cc/kg/day enteral feeds.

References:

See Clinical Strategies for managing hemorrhage and anemia without blood transfusion in the ICU.

Maier, RF; Oblader, M; et.al.: The effect of Epoetin beta on the need for transfusions in very low birth weight infants: New England Journal of Medicine. 1994:330:1173-1178

Ohls, R; Harcum, J; et.al. The effect of Erythropoietin on the transfusion requirements of preterm infants writhing 770 grams or less : A randomized, double blind, placebo controlled study. Journal of Pediatrics 1997; 131:661-665