Current Status of Platelet Transfusion in Pediatric Patients

Diagnostic Scores and Treatment Options for Acute Disseminated Intravascular Coagulation in Children

Disseminated intravascular coagulation (DIC) is a thrombo-hemorrhagic condition that commonly accompanies life-threatening illnesses in children and is associated with significant morbidity and mortality. Treatment of underlying conditions, hemodynamic support, and replacement therapy with blood components is the mainstay of DIC management. Limited research studies have supported the use of antithrombin (AT), recombinant thrombomodulin (rTM), and protein C concentrates (PrCC). Although there have been several studies and advancements in the DIC treatment in adults, data in pediatric patients are limited, and the consensus is lacking. Evidence validating the use of diagnostic scoring systems in the pediatric population is also limited. Since the hemostatic system differs significantly in children, especially in neonates, management of DIC is also different in children from that of adults, and there is a dire need for good quality research studies in this aspect.

We reviewed more than 100 articles in PubMed, Cochrane database, and Google Scholar. This traditional review article discusses different scoring systems for diagnosing DIC in pediatric patients, and different pharmacological treatment options for acute DIC in this population. This study mainly focuses on papers published from 1990 to 2021 and includes papers in all languages involving humans only.

Picking up the Pace: Decreasing Platelet Administration Safely and Effectively

BACKGROUND

Hematology-oncology patients often require blood and blood product transfusions, including platelets (PLTs), to maintain stability. Administering PLTs in a shorter timeframe may prove beneficial by possibly raising platelet counts to a higher level faster, and allowing patients to be disconnected from IV pumps sooner.

OBJECTIVE

To evaluate the optimal (safe and effective) transfusion time by comparing standard administration of PLTs over 2-4 h to the investigational administration of PLTs over 30-45 min in the pediatric hematology-oncology inpatient population.

METHODOLOGY

A pilot trial was conducted using a convenience sample of hematology-oncology children. Children prescribed a PLT transfusion while admitted to an inpatient unit were eligible. If randomized to the intervention group, the nurse administered the PLTs over 30-45 min. If randomized to the standard group, the nurse administered the PLTs over 2-4 h. Post transfusion PLTcount was drawn 30 min after completion. The child was monitored closely for adverse reactions.

RESULTS

Eleven participants were enrolled in the study and 20 PLT infusions administered. No adverse events were noted. There was not a significant difference in changes in PLT counts by group (post minus pre), p = 0.082. There was not a significant difference in post infusion PLT counts, p = 0.727. There was a significant difference in the rate of change in PLT counts by groups, p = 0.003.

NURSING IMPLICATIONS

This pilot study provides preliminary evidence that PLTs may be safely and effectively administered over 30-45 min in pediatric hematology-oncology patients. With quicker PLT administration, patients can be disconnected from IV pumps sooner.

Overview of Plasma and Platelet Transfusions in Critically Ill Children

Critically ill children are a unique population who frequently receive plasma and platelet transfusions for both active bleeding and mitigation of bleeding risk. While these products are frequently administered, transfusion indications in this population remain unclear, and practice varies across institutions and providers. In this manuscript, we will outline the current evidence regarding plasma and platelet transfusions for hemostasis in the pediatric intensive care setting. For both products, we will describe the product composition, epidemiology, and product indications and discuss the potential risks and benefits involved with the transfusion. We will also discuss knowledge gaps and future areas of research.

Evaluation of platelet concentrate prescription in pediatric patients at a tertiary care hospital

OBJECTIVE

To verify the adequacy of platelet concentrate prescription by pediatricians in different pediatric sectors of a general hospital.

METHODS

A cross-sectional study evaluating 218/227 platelet concentrate records in children and adolescents (zero to 13 years old), from January 2007 to April 2015, by the pediatricians of the emergency room, sick bay and intensive care unit. The requisitions were excluded in patients with hematological diseases and those without the number of platelets.

RESULTS

Children under 12 months received 98 platelet concentrates (45.2%). Most of the transfusions were prophylactic (165; 79%). Regarding the transfusion site, 39 (18%) were in the emergency room, 27 (12.4%) in the sick bay and 151 (69.6%) in the intensive care unit. The trigger, prescribed volume and platelet concentrate subtype were adequate in 59 (28.2%), 116 (53.5%) and 209 (96.3%) of the transfusions, respectively. Patients with hemorrhage presented adequacy in 42 (95.5%), while children without bleeding presented in 17 (10.3%). The most common inadequacy related to volume was the prescription above recommendation (95; 43.8%). Eight platelet concentrates were prescribed with subtype requests without indication.

CONCLUSION

The results obtained in this study showed that transfusion of platelet concentrate occurred more adequately in children with active bleeding compared to prophylactic transfusion. There was a tendency to prescribe high volumes and platelet subtypes not justified according to current protocols. The teaching of transfusion medicine should be more valued at undergraduate and medical residency.

Transfusion-related acute hepatic injury following postoperative platelets administration in pediatric patients undergoing the Fontan procedure

OBJECTIVE

The final common pathway of single ventricle patients is the Fontan procedure. Among the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]). We aimed to determine the contribution of blood products transfusion to acute hepatic injury.

DESIGN

Single center retrospective cohort study.

SETTING

Pediatric Cardiac Intensive Care Unit at a tertiary medical center.

PATIENTS

Ninety-nine pediatric patients undergoing the Fontan procedure between January 2009 and December 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Out of the four types of blood products, transfusion of platelets was found to significantly affect postoperative levels of ALT and AST. Additional factors included postoperative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Preoperative pulmonary artery pressure and pulmonary vascular resistance, cardiopulmonary bypass time, aortic cross-clamp time, amount of postoperative bleeding, and vasoactive-inotropic score did not influence liver enzymes levels CONCLUSIONS: In pediatric Fontan patients, platelets transfusions contribute to an acute hepatic injury. The relation between platelets and transfusion-related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regard to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed.

Pediatric red cell and platelet transfusions

The aim of pediatric transfusions should be based on the concept of avoiding unnecessary transfusions without jeopardizing the patient safety and providing correct blood components when there are well founded indications to transfuse. Despite considerable efforts from transfusion services to increase transfusion safety, transfusions are still associated with preventable and unpreventable adverse effects that may, in the worst case, have severe and fatal consequences. Transfusions to pediatric patients constitute a small proportion of all transfusions but have higher incidence of adverse events compared to adults. Pediatric transfusions consist of intrauterine transfusions, top-up transfusions to neonates and young children, exchange transfusions in the management of hemolytic disease of newborn (HDN), in addition to sickle cell crisis, chronic transfusion therapy in thalassemia patients, massive transfusion in trauma, HLA- and HPA-compatible platelets in immunized patients and neonates with fetal neonatal alloimmune thrombocytopenia (FNAIT). Packed red cells (PRCs) and platelet (PLT) concentrates are the most utilized blood components and will be reviewed here.