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Newborns undergoing surgery suffered worse outcomes if they had received preoperative blood transfusion, registry data showed.

The incidence of 30-day mortality (16.8% vs 2.6%, P<0.01) and morbidity (46.2% vs 16.2%, P<0.01) put neonates who received blood transfusion within 48 hours of surgery at a disadvantage compared with peers not getting transfusion, reported Loren Berman, MD, of Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware, and colleagues in the .

Blood transfusion remained associated with worse postoperative outcomes after multivariable adjustment and propensity-score matching, they noted.

Specific postoperative complications that occurred more frequently in the transfusion group included infection, bleeding requiring transfusion, reintubation, reoperation, and hospital stay beyond 30 days.

However, babies who did not receive transfusion had more readmissions within 30 days of surgery.

"This finding can be explained by the fact that those neonates who received a PBT [preoperative blood transfusion] were more likely to remain in the hospital for >30 days postoperatively and were therefore ineligible for readmission," Berman's group reasoned.

"This study is the first to describe the association between preoperative transfusions and worse postoperative outcomes and raises questions about the safety of liberal approaches to transfusion in neonates undergoing surgery," they wrote.

Transfusion practices in neonatal ICUs remain highly variable despite several randomized trials showing in babies compared with a liberal one, they noted. It's not uncommon for anemic newborns to receive transfusions prior to surgery as a precaution.

Berman's team identified 12,184 neonates who underwent surgery as listed in the American College of Surgeons National Surgical Quality Improvement Program in 2012-2015. Of these babies, 9.9% received a preoperative blood transfusion for .

Transfusion was more likely in babies who were premature or had chronic lung disease, cardiac disease, or required ventilatory support.

There appeared to be a stronger relationship between mortality and morbidity and blood transfusion with rising preoperative hematocrit (up to 35%), though this finding did not reach statistical significance for interaction, the investigators reported.

"It is likely that there is a tipping point or range in which the risks associated with anemia outweigh the risks associated with blood transfusion," Berman's group suggested.

"For infants with significant anemia, it is plausible that the benefits of a blood transfusion, such as increased oxygen delivery, outweigh the associated risks (i.e., transfusion-related immunomodulation and a proinflammatory state), but as the anemia becomes less severe, the harm of a blood transfusion begins to outweigh the benefit," they continued.

They acknowledged that their retrospective study design left room for selection bias. In addition, the database used captured only transfusion of packed red blood cells and whole blood.

"A prospective trial is needed to define transfusion thresholds that maximize the benefit of treatment of anemia and minimize the risk associated with transfusion," wrote Berman and colleagues.

In the meantime, preoperative blood transfusion appears to be associated with increased harm among newborns undergoing surgery, they concluded.

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