Perioperative blood management in neonatal major non-cardiac surgery: A state-of-the-art narrative review highlighting evidence gaps and practice variabilities

Abstract

Background: Neonates undergoing major non-cardiac surgery are highly susceptible to anaemia, perioperative blood loss and transfusion exposure. Perioperative blood management (PBM) in this population is challenging due to limited physiological reserve and the absence of robust, neonatal-specific evidence to guide practice. Aim: To evaluate the epidemiology of blood transfusion and current evidence on PBM in neonates undergoing major non-cardiac surgery. Method: A state-of-the-art narrative review was conducted across PubMed, Web of Science and Scopus for studies published between January 2015 and December 2025. Eligible studies included primary research involving neonates (≤ 28 days) undergoing major non-cardiac surgery and reporting on transfusion practices, anaemia management, perioperative blood loss or related epidemiologic outcomes. Study selection followed predefined Population, Intervention/Exposure, Comparator and Outcomes criteria. Results: A very limited number of studies met inclusion criteria, with most excluded due to non-neonatal populations, a lack of surgical context or absence of blood management outcomes. Included studies were predominantly observational and demonstrated marked heterogeneity in transfusion practices. Evidence regarding transfusion thresholds, perioperative blood loss and PBM strategies was sparse and inconsistent. No high-quality trials directly evaluating PBM interventions in this population were identified. Conclusion: There is a critical lack of high-quality evidence guiding PBM in neonatal major non-cardiac surgery. Current practices are largely extrapolated from older populations. Well-designed prospective and multicentre studies are urgently needed to establish evidence-based transfusion thresholds and optimise PBM strategies in this vulnerable group. Contribution: This review synthesises evidence on neonatal perioperative blood management, revealing transfusion practice variability, evidence gaps, and the need for neonatal-specific guidelines.