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Christensen RD, Bahr TM, Davenport P, Sola-Visner MC, Ohls RK, Ilstrup SJ, Kelley WE. Implementing evidence-based restrictive neonatal intensive care unit platelet transfusion guidelines. J Perinatol 2024:10.1038/s41372-024-02050-x. [PMID: 39009717 DOI: 10.1038/s41372-024-02050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 07/03/2024] [Accepted: 07/04/2024] [Indexed: 07/17/2024]
Abstract
Platelet transfusions are life-saving treatments for specific populations of neonates. However, recent evidence indicates that liberal prophylactic platelet transfusion practices cause harm to premature neonates. New efforts to better balance benefits and risks are leading to the adoption of more restrictive platelet transfusion guidelines in neonatal intensive care units (NICU). Although restrictive guidelines have the potential to improve outcomes, implementation barriers exist. We postulate that as neonatologists become more familiar with the data on the harm of liberal platelet transfusions, enthusiasm for restrictive guidelines will increase and barriers to implementation will decrease. Thus, we focused this educational review on; (1) the adverse effects of platelet transfusions to neonates, (2) awareness of platelet transfusion "refractoriness" in thrombocytopenic neonates and its association with poor outcomes, and (3) the impetus to find alternatives to transfusing platelets from adult donors to NICU patients.
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Affiliation(s)
- Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
- Women and Newborns Research, Intermountain Health, Murray, UT, USA.
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
- Women and Newborns Research, Intermountain Health, Murray, UT, USA
| | - Patricia Davenport
- Division of Newborn Medicine Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Martha C Sola-Visner
- Division of Newborn Medicine Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Sarah J Ilstrup
- Transfusion Medicine, Department of Pathology, Intermountain Health, Murray, UT, USA
| | - Walter E Kelley
- American National Red Cross, Salt Lake City, UT, USA
- Department of Pathology, University of Arizona College of Medicine, Tucson, AZ, USA
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2
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Berna-Erro A, Granados MP, Rosado JA, Redondo PC. Thrombotic Alterations under Perinatal Hypoxic Conditions: HIF and Other Hypoxic Markers. Int J Mol Sci 2023; 24:14541. [PMID: 37833987 PMCID: PMC10572648 DOI: 10.3390/ijms241914541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/15/2023] Open
Abstract
Hypoxia is considered to be a stressful physiological condition, which may occur during labor and the later stages of pregnancy as a result of, among other reasons, an aged placenta. Therefore, when gestation or labor is prolonged, low oxygen supply to the tissues may last for minutes, and newborns may present breathing problems and may require resuscitation maneuvers. As a result, poor oxygen supply to tissues and to circulating cells may last for longer periods of time, leading to life-threatening conditions. In contrast to the well-known platelet activation that occurs after reperfusion of the tissues due to an ischemia/reperfusion episode, platelet alterations in response to reduced oxygen exposition following labor have been less frequently investigated. Newborns overcome temporal hypoxic conditions by changing their organ functions or by adaptation of the intracellular molecular pathways. In the present review, we aim to analyze the main platelet modifications that appear at the protein level during hypoxia in order to highlight new platelet markers linked to complications arising from temporal hypoxic conditions during labor. Thus, we demonstrate that hypoxia modifies the expression and activity of hypoxic-response proteins (HRPs), including hypoxia-induced factor (HIF-1), endoplasmic reticulum oxidase 1 (Ero1), and carbonic anhydrase (CIX). Finally, we provide updates on research related to the regulation of platelet function due to HRP activation, as well as the role of HRPs in intracellular Ca2+ homeostasis.
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Affiliation(s)
- Alejandro Berna-Erro
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
| | | | - Juan Antonio Rosado
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
| | - Pedro Cosme Redondo
- Department of Physiology (Phycell), University of Extremadura, Avd de la Universidad s/n, 10003 Caceres, Spain; (A.B.-E.); (P.C.R.)
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3
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Khizroeva J, Makatsariya A, Vorobev A, Bitsadze V, Elalamy I, Lazarchuk A, Salnikova P, Einullaeva S, Solopova A, Tretykova M, Antonova A, Mashkova T, Grigoreva K, Kvaratskheliia M, Yakubova F, Degtyareva N, Tsibizova V, Gashimova N, Blbulyan D. The Hemostatic System in Newborns and the Risk of Neonatal Thrombosis. Int J Mol Sci 2023; 24:13864. [PMID: 37762167 PMCID: PMC10530883 DOI: 10.3390/ijms241813864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Newborns are the most vulnerable patients for thrombosis development among all children, with critically ill and premature infants being in the highest risk group. The upward trend in the rate of neonatal thrombosis could be attributed to progress in the treatment of severe neonatal conditions and the increased survival in premature babies. There are physiological differences in the hemostatic system between neonates and adults. Neonates differ in concentrations and rate of synthesis of most coagulation factors, turnover rates, the ability to regulate thrombin and plasmin, and in greater variability compared to adults. Natural inhibitors of coagulation (protein C, protein S, antithrombin, heparin cofactor II) and vitamin K-dependent coagulation factors (factors II, VII, IX, X) are low, but factor VIII and von Willebrand factor are elevated. Newborns have decreased fibrinolytic activity. In the healthy neonate, the balance is maintained but appears more easily converted into thrombosis. Neonatal hemostasis has less buffer capacity, and almost 95% of thrombosis is provoked. Different triggering risk factors are responsible for thrombosis in neonates, but the most important risk factors for thrombosis are central catheters, fluid fluctuations, liver dysfunction, and septic and inflammatory conditions. Low-molecular-weight heparins are the agents of choice for anticoagulation.
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Affiliation(s)
- Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
- Hematology and Thrombosis Center, Tenon Hospital, Sorbonne University, 4 Rue de la Chine, 75020 Paris, France
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Sabina Einullaeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Antonina Solopova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Maria Tretykova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexandra Antonova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Tamara Mashkova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Valentina Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, 2 Akkuratova Str., 197341 Saint Petersburg, Russia;
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - David Blbulyan
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
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4
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Abstract
Platelet plug formation is critically involved in murine ductus arteriosus closure and thrombocytopenia in preterm infants seems to negatively affect spontaneous and pharmacologically induced ductal closure. Furthermore, platelet dysfunction may contribute to ductal patency, especially in extremely immature infants. Neonatal platelets likely have multifaceted roles during ductal closure, such as secretion of several signaling molecules and facilitation of specific cell-cell interactions. The only available randomized-controlled trial on platelet transfusions in preterm infants with patent ductus arteriosus demonstrated that a liberal transfusion regimen did not promote ductal closure, but was associated with an increased rate of intraventricular hemorrhage. Herein, we discuss the available mechanistic evidence on the role of platelets in ductus arteriosus closure and their potential clinical implications in preterm infants. We further briefly outline future research directions aimed at a better understanding of platelet-endothelial interactions in neonatal health and disease.
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Affiliation(s)
- Hannes Sallmon
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Division of Pediatric Cardiology, Graz Medical University, Graz, Austria.
| | - Cassidy A Delaney
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora CO, USA
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5
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Hovgesen NT, Hviid CVB, Grevsen AK, Hansen AK, Hvas AM. Reduced platelet function in preterm neonates compared with term neonates. Res Pract Thromb Haemost 2022; 6:e12751. [PMID: 35928524 PMCID: PMC9343599 DOI: 10.1002/rth2.12751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/25/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022] Open
Abstract
Background A reduced platelet function might contribute to the longer bleeding time seen in preterm neonates. However, the previously used platelet function testing in neonates is limited due to methodological limitations, mainly caused by difficulties in obtaining adequate blood volume. Therefore, the platelet function in preterm neonates is sparsely investigated. The aim of this study was to compare platelet function in preterm neonates at birth and at expected term age with platelet function in term neonates at birth. Methods We included 43 preterm neonates born at gestational age (GA) 28 + 0 to 34 + 0 and 21 term neonates born at GA 38 + 0 to 41 + 0. Within the first 24 hours of life, 1-1.5 mL peripheral blood was obtained and for preterm neonates, resampling was performed at expected term age (GA 38 + 0 to 41 + 0). Platelet function testing included impedance aggregometry and platelet activation measured by flow cytometry. In addition, platelet count was determined. Results Platelet count and platelet activation were reduced in preterm neonates compared with term neonates at birth, but we found no difference in impedance aggregometry at birth. At expected term age, platelet count and aggregation exceeded term levels, but platelet activation remained impaired in the preterm. Conclusion Preterm neonatal function is decreased at birth and does not seem to reach term levels during the first 4 to 13 weeks of life.
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Affiliation(s)
- Nadia Thrane Hovgesen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | - Claus V B Hviid
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | - Alexander K Grevsen
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark
| | - Anne Kirkeby Hansen
- Neonatal Intensive Care Unit, Department of Pediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
| | - Anne-Mette Hvas
- Thrombosis and Hemostasis Research Unit, Department of Clinical Biochemistry Aarhus University Hospital Aarhus Denmark.,Department of Clinical Medicine Aarhus University Aarhus Denmark
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6
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Abstract
The neonatal hemostatic system is different from that of adults. The differences in levels of procoagulant and anticoagulant factors and the evolving equilibrium in secondary hemostasis during the transition from fetal/neonatal life to infancy, childhood, and adult life are known as "developmental hemostasis." In regard to primary hemostasis, while the number (150,000-450,000/µl) and structure of platelets in healthy neonates closely resemble those of adults, there are significant functional differences between neonatal and adult platelets. Specifically, platelets derived from both cord blood and neonatal peripheral blood are less reactive than adult platelets to agonists, such as adenosine diphosphate (ADP), epinephrine, collagen, thrombin, and thromboxane (TXA2) analogs. This platelet hyporeactivity is due to differences in expression levels of key surface receptors and/or in signaling pathways, and is more pronounced in preterm neonates. Despite these differences in platelet function, bleeding times and PFA-100 closure times (an in vitro test of whole-blood primary hemostasis) are shorter in healthy full-term infants than in adults, reflecting enhanced primary hemostasis. This paradoxical finding is explained by the presence of factors in neonatal blood that increase the platelet-vessel wall interaction, such as high von Willebrand factor (vWF) levels, predominance of ultralong vWF multimers, high hematocrit, and high red cell mean corpuscular volume. Thus, the hyporeactivity of neonatal platelets should not be viewed as a developmental deficiency, but rather as an integral part of a developmentally unique, but well balanced, primary hemostatic system. In clinical practice, due to the high incidence of bleeding (especially intraventricular hemorrhage, IVH) among preterm infants, neonatologists frequently transfuse platelets to non-bleeding neonates when platelet counts fall below an arbitrary limit, typically higher than that used in older children and adults. However, recent studies have shown that prophylactic platelet transfusions not only fail to decrease bleeding in preterm neonates, but are associated with increased neonatal morbidity and mortality. In this review, we will describe the developmental differences in platelet function and primary hemostasis between neonates and adults, and will analyze the implications of these differences to platelet transfusion decisions.
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Affiliation(s)
- Francisca Ferrer-Marín
- Hematology and Medical Oncology Department. Hospital UniversitarioMorales-Meseguer. Centro Regional de Hemodonación. IMIB-Arrixaca. Murcia, Spain,CIBERER CB15/00055, Murcia, Spain,Grado de Medicina. Universidad Católica San Antonio (UCAM)
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
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7
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Kollia M, Iacovidou N, Iliodromiti Z, Pouliakis A, Sokou R, Mougiou V, Boutsikou M, Politou M, Boutsikou T, Valsami S. Primary hemostasis in fetal growth restricted neonates studied via PFA-100 in cord blood samples. Front Pediatr 2022; 10:946932. [PMID: 36160789 PMCID: PMC9492943 DOI: 10.3389/fped.2022.946932] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Platelet function of fetal growth restricted (FGR) neonates remains a field of debate. Platelet function analyzer (PFA-100) offers a quantitative in vitro assessment of primary, platelet-related hemostasis. Our aim was to examine platelet function using PFA-100 in FGR neonates and associate our results with perinatal parameters. METHODS PFA-100 was applied on 74 FGR neonates, 48 full-term (>37 weeks' gestation) and 26 preterm neonates (<37 weeks). The control group consisted of 118 healthy neonates. Two closure times (CTs) with COL/EPI and COL/ADP cartridges were determined on cord blood samples for each subject. Statistical analysis was performed by SAS 9.4. The statistical significance level was set at 0.05 and all tests were two-tailed. RESULTS COL/EPI CTs were prolonged in FGR (median 132 s, IQR 95-181 s) compared with control neonates (median 112.5 s, IQR 93-145 s), p = 0.04. Median COL/EPI CT for term and preterm FGR neonates was 126 s (IQR 90-157 s) and 137 s (IQR 104-203), respectively (p = 0.001), and COL/ADP CT was 70 s (IQR 62-80 s) for term and 75 s (IQR 68-82 s) for preterm FGR neonates (p = 0.08). Among FGR neonates, COL/EPI CT was related with delivery time (with preterm neonates exhibiting prolonged COL/EPI CTs), p = 0.05. No correlation was proved between both CTs and hematological parameters in FGR neonates. CONCLUSION FGR neonates showed impaired platelet function via PFA-100, with preterm FGR neonates confronting the greatest risk. Prolonged COL/EPI CTs in FGR neonates seemed to be independent of hematological parameters and could warn for closer evaluation during the first days of their lives.
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Affiliation(s)
- Maria Kollia
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Zoi Iliodromiti
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Abraham Pouliakis
- 2nd Department of Pathology, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Rozeta Sokou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Vasiliki Mougiou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Boutsikou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Politou
- Haematology Laboratory-Blood Bank, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Boutsikou
- Neonatal Department, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Serena Valsami
- Haematology Laboratory-Blood Bank, Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
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8
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Cortesi V, Raffaeli G, Amelio GS, Amodeo I, Gulden S, Manzoni F, Cervellini G, Tomaselli A, Colombo M, Araimo G, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Hemostasis in neonatal ECMO. Front Pediatr 2022; 10:988681. [PMID: 36090551 PMCID: PMC9458915 DOI: 10.3389/fped.2022.988681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
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Affiliation(s)
- Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Araimo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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9
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Individualized Bleeding Risk Assessment through Thromboelastography: A Case Report of May-Hegglin Anomaly in Preterm Twin Neonates. CHILDREN-BASEL 2021; 8:children8100878. [PMID: 34682143 PMCID: PMC8534760 DOI: 10.3390/children8100878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
May–Hegglin anomaly (MHA) is a rare autosomal dominant disorder in the spectrum of myosin heavy chain-related disorders (MYH9-RD), characterized by congenital macrothrombocytopenia and white blood cell inclusions. MHA carries a potential risk of hemorrhagic complications. Bleeding diathesis is usually mild, but sporadic, life-threatening events have been reported. Data regarding the clinical course and outcomes of neonatal MYH9-RD are limited, and specific guidelines on platelet transfusion in asymptomatic patients are lacking. We present monochorionic twins born preterm at 32 weeks of gestation to an MHA mother; both presented with severe thrombocytopenia at birth. Peripheral blood smear demonstrated the presence of macrothrombocytes, and immunofluorescence confirmed the diagnosis of MHA. Close clinical monitoring excluded bleeding complications, and serial hemostatic assessments through a viscoelastic system demonstrated functionally normal primary hemostasis in both patients. Therefore, prophylactic platelet transfusions were avoided. Whole DNA sequencing confirmed the pathogenetic variant of MHA of maternal origin in both twins. Thromboelastography allowed real-time bedside bleeding risk assessment and supported individualized transfusion management in preterm newborns at risk of hemostatic impairment. This report suggests that dynamic and appropriate clotting monitoring may contribute to the more rational use of platelets’ transfusions while preserving patients with hemorrhagic complications and potential transfusion-related side effects.
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10
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:diagnostics11091642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
- Correspondence: ; Tel.: +39-0521-903524
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11
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Very preterm birth results in later lower platelet activation markers. Pediatr Res 2021; 89:1278-1282. [PMID: 32698194 DOI: 10.1038/s41390-020-1070-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/12/2020] [Accepted: 07/09/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Premature birth entails an adverse cardiovascular risk profile, but the underlying mechanisms are insufficiently understood. Here, we employed an unbiased cardiovascular proteomics approach to profile former very preterm-born preschoolers. METHODS This observational study investigated differences in plasma concentrations of 79 proteins, including putative cardiovascular biomarkers between very preterm- and term-born children on average 5.5 years old (53.1% male) using multiple-reaction monitoring mass spectrometry. RESULTS Very preterm-born (n = 38; median gestational age 29.6 weeks) compared to term-born (n = 26; 40.2 weeks) children featured lower plasma concentrations of platelet factor 4 (PLF4; -61.6%, P < 0.0001), platelet basic protein (CXCL7; -57.8%, P < 0.0001), and hemoglobin subunit beta (-48.3%, P < 0.0001). Results remained virtually unchanged when adjusting for complete blood count parameters, including platelet count. Conversely, whole blood hemoglobin was higher (+7.62%, P < 0.0001) in preterm-born children. CONCLUSIONS Very preterm birth was associated with decreased markers of platelet activation among preschoolers. These findings are consistent with reduced platelet reactivity persisting from very preterm birth to a preschool age. IMPACT Former very preterm-born preschoolers featured reduced levels of platelet activation markers. While lower platelet reactivity in very preterm-born compared to term-born infants in the first days of life was established, it was unknown when, if at all, reactivity normalizes. The current study suggests that platelet hyporeactivity due to very preterm birth persists at least up to a preschool age. "Immaturity of the hemostatic system" may be a persistent sequel of preterm birth, but larger studies are needed to investigate its potential clinical implications.
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12
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Abstract
The neonatal hemostatic system is strikingly different from that of adults. Among other differences, neonates exhibit hyporeactive platelets and decreased levels of coagulation factors, the latter translating into prolonged clotting times (PT and PTT). Since pre-term neonates have a high incidence of bleeding, particularly intraventricular hemorrhages, neonatologists frequently administer blood products (i.e., platelets and FFP) to non-bleeding neonates with low platelet counts or prolonged clotting times in an attempt to overcome these "deficiencies" and reduce bleeding risk. However, it has become increasingly clear that both the platelet hyporeactivity as well as the decreased coagulation factor levels are effectively counteracted by other factors in neonatal blood that promote hemostasis (i.e., high levels of vWF, high hematocrit and MCV, reduced levels of natural anticoagulants), resulting in a well-balanced neonatal hemostatic system, perhaps slightly tilted toward a prothrombotic phenotype. While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelets. In this review, we will present a clinical overview of bleeding in neonates (incidence, sites, risk factors), followed by a description of the key developmental differences between neonates and adults in primary and secondary hemostasis. Next, we will review the clinical tests available for the evaluation of bleeding neonates and their limitations in the context of the developmentally unique neonatal hemostatic system, and will discuss current and emerging approaches to more accurately predict, evaluate and treat bleeding in neonates.
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Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States
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13
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Abstract
Although the hemostatic potential of adult platelets has been investigated extensively, regulation of platelet function during fetal life is less clear. Recent studies have provided increasing evidence for a developmental control of platelet function during fetal ontogeny. Fetal platelets feature distinct differences in reactive properties compared with adults. These differences very likely reflect a modified hemostatic and homeostatic environment in which platelet hyporeactivity contributes to prevent pathological clot formation on the one hand but still ensures sufficient hemostasis on the other hand. In this review, recent findings on the ontogeny of platelet function and reactivity are summarized, and implications for clinical practice are critically discussed. This includes current platelet-transfusion practice and its potential risk in premature infants and neonates.
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14
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Haidl H, Zöhrer E, Pohl S, Leschnik B, Weiss EC, Gallistl S, Muntean W, Schlagenhauf A. New insights into neonatal coagulation: normal clot formation despite lower intra-clot thrombin levels. Pediatr Res 2019; 86:719-724. [PMID: 31404918 DOI: 10.1038/s41390-019-0531-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Healthy neonates exhibit no bleeding tendencies, but exhibit longer partial thromboplastin times than adults. Lower clotting factor levels may be balanced by lower inhibitor levels, which is not reflected in routine coagulation assays, but could result in normal clot formation in vivo. The novel thrombodynamics assay simulates a damaged vessel with tissue factor immobilized to a surface. We hypothesized that intra-clot thrombin levels and spatial fibrin clot formation with this assay are comparable in neonates and adults. METHODS Coagulation was tested in plasma from venous neonatal blood (N = 12), cord blood (N = 30), and adult blood (N = 20) using thrombodynamics and calibrated automated thrombography. RESULTS Neonates exhibited a higher initial rate of clot formation than adults (adult: 60.7 ± 3.9 µm/min; neonatal: 66.8 ± 3.9 µm/min; cord: 68.1 ± 3.3 µm/min; P < 0.001) and a comparable stationary rate of clot formation (adult: 35.8 ± 8.5 µm/min; neonatal: 37.0 ± 4.6 µm/min; cord: 36.0 ± 5.2 µm/min; P = 0.834). Intra-clot thrombin levels were lower in neonates (adult: 41.9 ± 11.2 AU/l; neonatal: 22.6 ± 10.2 AU/l; cord: 23.6 ± 9.7 AU/l; P < 0.001), but the longitudinal rate of thrombin propagation was comparable (adult: 27.2 ± 4.2 µm/min neonatal; 27.9 ± 2.9 µm/min; cord: 27.6 ± 3.4 µm/min; P = 0.862). CONCLUSIONS Despite lower intra-clot thrombin levels, neonates exhibit normal spatial fibrin clot growth, which concurs with clinically well-functioning hemostasis in healthy neonates.
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Affiliation(s)
- Harald Haidl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Evelyn Zöhrer
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Sina Pohl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bettina Leschnik
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Eva-Christine Weiss
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria
| | - Siegfried Gallistl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Wolfgang Muntean
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Axel Schlagenhauf
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
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15
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Krogh AKH, Brunse A, Thymann T, Bochsen L, Kristensen AT. Staphylococcus epidermidis sepsis induces hypercoagulability in preterm pigs. Res Vet Sci 2019; 127:122-129. [PMID: 31704497 DOI: 10.1016/j.rvsc.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/30/2022]
Abstract
Gram positive bacteria are a cause of sepsis in human preterm infants, and associates with high mortality and hemostatic dysfunction. It is unknown whether bovine colostrum may protect against sepsis and prevent hemostatic dysfunction. The current study was part of an overall sepsis study investigating Staphylococcus epidermidis (SE) induced sepsis in premature pigs including investigation of the effect of feeding bovine colostrum. The specific hypothesis of this study was that the hemostatic response would be hypercoagulable in septic pigs compared to non-infected controls, and that feeding bovine colostrum would increase the hypercoagulant response. Thromboelastography, activated partial thromboplastin time, prothrombin time and fibrinogen concentration were characterized in SE infected pigs, SE infected pigs fed bovine colostrum, and uninfected controls. All pigs were followed for 24 h. In addition, the same parameters were evaluated in a group of premature pigs and a group of full born pigs all followed for 11 days. SE septic premature pigs were characterized by increased clot strength and decreased fibrinolysis, significantly low platelet count and high fibrinogen concentration. Feeding bovine colostrum did not affect the hemostatic response. Compared to full born pigs, preterm newborn pigs demonstrated reduced clot strength, prolonged prothrombin time and low fibrinogen concentration. In all pigs, the fibrinogen concentration increased 11 days post-partum. To conclude, SE induced sepsis in premature pigs resulted in hypercoagulability. Bovine colostrum did not mitigate the hemostatic response. A hypocoagulable hemostatic response was present in healthy preterm pigs compared to full born pigs, similar to previous reports in infants.
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Affiliation(s)
- Anne Kirstine Havnsøe Krogh
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Anders Brunse
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Thomas Thymann
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Louise Bochsen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Annemarie T Kristensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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16
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Christensen RD. Medicinal Uses of Hematopoietic Growth Factors in Neonatal Medicine. Handb Exp Pharmacol 2019; 261:257-283. [PMID: 31451971 DOI: 10.1007/164_2019_261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
This review focuses on certain hematopoietic growth factors that are used as medications in clinical neonatology. It is important to note at the chapter onset that although all of the pharmacological agents mentioned in this review have been approved by the US Food and Drug administration for use in humans, none have been granted a specific FDA indication for neonates. Thus, in a sense, all of the agents mentioned in this chapter could be considered experimental, when used in neonates. However, a great many of the pharmacological agents utilized routinely in neonatology practice do not have a specific FDA indication for this population of patients. Consequently, many of the agents reviewed in this chapter are considered by some practitioners to be nonexperimental and are used when they judge such use to be "best practice" for the disorders under treatment.The medicinal uses of the agents in this chapter vary considerably, between geographic locations, and sometimes even within an institutions. "Consistent approaches" aimed at using these agents in uniform ways in the practice of neonatology are encouraged. Indeed some healthcare systems, and some individual NICUs, have developed written guidelines for using these agents within the practice group. Some such guidelines are provided in this review. It should be noted that these guidelines, or "consistent approaches," must be viewed as dynamic and changing, requiring adjustment and refinement as additional evidence accrues.
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Affiliation(s)
- Robert D Christensen
- Divisions of Neonatology and Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA. .,Intermountain Healthcare, Salt Lake City, UT, USA.
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17
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Van Ommen CH, Neunert CE, Chitlur MB. Neonatal ECMO. Front Med (Lausanne) 2018; 5:289. [PMID: 30410882 PMCID: PMC6209668 DOI: 10.3389/fmed.2018.00289] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/21/2018] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is becoming increasingly utilized to manage neonates with cardiac and respiratory failure. The procedure involves extensive anticoagulation in a sick neonate with underlying disease pathology. In addition, the immature hemostatic system in the neonate adds to the complexity of titrating the necessary anticoagulation. This places the infant at greater risk for life threatening hemorrhage and thrombosis. Managing anticoagulation in these infants is extremely challenging and needs the expertise of a physician with a thorough knowledge of the intricacies of developmental hemostasis and limitations of the current laboratory techniques available to manage anticoagulation. This article provides a brief overview of the developing hemostatic system of the neonate and the challenges associated with managing anticoagulation in this vulnerable population of patients.
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Affiliation(s)
| | - Cindy E Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Meera B Chitlur
- Division of Hematology, Oncology, Carmen and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
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18
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Revel-Vilk S. Neonatal haemostasis. Hamostaseologie 2017; 36:261-264. [DOI: 10.5482/hamo-15-11-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/14/2016] [Indexed: 11/05/2022] Open
Abstract
SummaryThe maturation and postnatal development of the human coagulation system results in significant and important differences in the coagulation and fibrinolysis of neonates and young children compared to older children and adults. Importantly, these differences, which mostly reflect the immaturity of the neonatal haemostasis system, are functionally balanced. Healthy neonates show no signs of easy bruising or other bleeding diathesis and no increased tendency to thrombosis for any given stimulus compared to adults.Systemic diseases may affect haemostasis, thus predisposing ill neonates to increased risk for haemorrhagic or thrombotic complications. In hospitalized children, neonates have increased risk of developing thrombosis compared to infants and children, mostly associated with the presence of central venous catheter. For diagnosis of haemostasis disorders, diagnostic laboratories processing pediatric samples should use age, analyzer and reagent appropriate reference ranges. Age specific guidelines should be followed for the management of neonates with hemostatic disorders.
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19
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Reference intervals of citrated-native whole blood thromboelastography in premature neonates. Early Hum Dev 2017; 115:60-63. [PMID: 28923772 DOI: 10.1016/j.earlhumdev.2017.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/21/2017] [Accepted: 09/09/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bleeding due to acquired coagulation disorders is a common complication in premature neonates. In this clinical setting, standard coagulation laboratory tests might be unsuitable to investigate the hemostatic function as they reflect the concentration of pro-coagulant proteins but not of anti-coagulant proteins. Thromboelastography (TEG), providing a more complete assessment of hemostasis, may be able to overcome some of these limitations. Unfortunately, experience on the use of TEG in premature neonates is very limited and, in particular in this population, reference ranges of TEG parameters have not been yet evaluated. AIMS To evaluate TEG in preterm neonates, and to assess their reference ranges. METHODS One hundred and eighteen preterm neonates were analyzed for TEG in a retrospective cohort study. Double-sided 95% reference intervals were calculated using a bootstrap method after Box-Cox transformation. TEG parameters were compared between early-preterm and moderate-/late-preterm neonates and between bleeding and non-bleeding preterm neonates. RESULTS Comparing early-preterm with moderate-/late-preterm neonates, TEG parameters were not statistically different, except for fibrinolysis which was significantly higher in early preterm neonates. Platelet count significantly correlated with α angle and MA parameters. Bleeding and non-bleeding neonates had similar TEG values. CONCLUSIONS These results reinforce the concept that in stable preterm neonates, in spite of lower concentration of pro- and anti-coagulants proteins, the hemostasis is normally balanced and well functioning.
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20
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Strauss T, Elisha N, Ravid B, Rosenberg N, Lubetsky A, Levy-Mendelovich S, Morag I, Nowak Göttl U, Kenet G. Activity of Von Willebrand factor and levels of VWF-cleaving protease (ADAMTS13) in preterm and full term neonates. Blood Cells Mol Dis 2017; 67:14-17. [DOI: 10.1016/j.bcmd.2016.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 12/18/2022]
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21
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Nygaard G, Herfindal L, Asrud KS, Bjørnstad R, Kopperud RK, Oveland E, Berven FS, Myhren L, Hoivik EA, Lunde THF, Bakke M, Døskeland SO, Selheim F. Epac1-deficient mice have bleeding phenotype and thrombocytes with decreased GPIbβ expression. Sci Rep 2017; 7:8725. [PMID: 28821815 PMCID: PMC5562764 DOI: 10.1038/s41598-017-08975-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/17/2017] [Indexed: 11/16/2022] Open
Abstract
Epac1 (Exchange protein directly activated by cAMP 1) limits fluid loss from the circulation by tightening the endothelial barrier. We show here that Epac1-/- mice, but not Epac2-/- mice, have prolonged bleeding time, suggesting that Epac1 may limit fluid loss also by restraining bleeding. The Epac1-/- mice had deficient in vitro secondary hemostasis. Quantitative comprehensive proteomics analysis revealed that Epac1-/- mouse platelets (thrombocytes) had unbalanced expression of key components of the glycoprotein Ib-IX-V (GPIb-IX-V) complex, with decrease of GP1bβ and no change of GP1bα. This complex is critical for platelet adhesion under arterial shear conditions. Furthermore, Epac1-/- mice have reduced levels of plasma coagulation factors and fibrinogen, increased size of circulating platelets, increased megakaryocytes (the GP1bβ level was decreased also in Epac1-/- bone marrow) and higher abundance of reticulated platelets. Viscoelastic measurement of clotting function revealed Epac1-/- mice with a dysfunction in the clotting process, which corresponds to reduced plasma levels of coagulation factors like factor XIII and fibrinogen. We propose that the observed platelet phenotype is due to deficient Epac1 activity during megakaryopoiesis and thrombopoiesis, and that the defects in blood clotting for Epac1-/- is connected to secondary hemostasis.
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Affiliation(s)
- Gyrid Nygaard
- Department of Biomedicine, University of Bergen, Bergen, Norway
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Lars Herfindal
- Centre for Pharmacy, Department of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Ronja Bjørnstad
- Centre for Pharmacy, Department of Clinical Science, University of Bergen, Bergen, Norway
- Hospital Pharmacies Enterprise, Western Norway, Bergen, Norway
| | | | - Eystein Oveland
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Frode S Berven
- Department of Biomedicine, University of Bergen, Bergen, Norway
- The Proteomics Unit at the University of Bergen, Bergen, Norway
| | - Lene Myhren
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | - Erling A Hoivik
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Turid Helen Felli Lunde
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
| | - Marit Bakke
- Department of Biomedicine, University of Bergen, Bergen, Norway
| | | | - Frode Selheim
- Department of Biomedicine, University of Bergen, Bergen, Norway.
- The Proteomics Unit at the University of Bergen, Bergen, Norway.
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22
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Margraf A, Nussbaum C, Rohwedder I, Klapproth S, Kurz ARM, Florian A, Wiebking V, Pircher J, Pruenster M, Immler R, Dietzel S, Kremer L, Kiefer F, Moser M, Flemmer AW, Quackenbush E, von Andrian UH, Sperandio M. Maturation of Platelet Function During Murine Fetal Development In Vivo. Arterioscler Thromb Vasc Biol 2017; 37:1076-1086. [PMID: 28428216 DOI: 10.1161/atvbaha.116.308464] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 04/07/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Platelet function has been intensively studied in the adult organism. However, little is known about the function and hemostatic capacity of platelets in the developing fetus as suitable in vivo models are lacking. APPROACH AND RESULTS To examine fetal platelet function in vivo, we generated a fetal thrombosis model and investigated light/dye-induced thrombus formation by intravital microscopy throughout gestation. We observed that significantly less and unstable thrombi were formed at embryonic day (E) 13.5 compared with E17.5. Flow cytometry revealed significantly lower platelet counts in E13.5 versus E17.5 fetuses versus adult controls. In addition, fetal platelets demonstrated changed activation responses of surface adhesion molecules and reduced P-selectin content and mobilization. Interestingly, we also measured reduced levels of the integrin-activating proteins Kindlin-3, Talin-1, and Rap1 during fetal development. Consistently, fetal platelets demonstrated diminished spreading capacity compared with adults. Transfusion of adult platelets into the fetal circulation led to rapid platelet aggregate formation even in young fetuses. Yet, retrospective data analysis of a neonatal cohort demonstrated no correlation of platelet transfusion with closure of a persistent ductus arteriosus, a process reported to be platelet dependent. CONCLUSIONS Taken together, we demonstrate an ontogenetic regulation of platelet function in vivo with physiologically low platelet numbers and hyporeactivity early during fetal development shedding new light on hemostatic function during fetal life.
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Affiliation(s)
- Andreas Margraf
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Claudia Nussbaum
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Ina Rohwedder
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Sarah Klapproth
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Angela R M Kurz
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Annamaria Florian
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Volker Wiebking
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Joachim Pircher
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Monika Pruenster
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Roland Immler
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Steffen Dietzel
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Ludmila Kremer
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Friedemann Kiefer
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Markus Moser
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Andreas W Flemmer
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Elizabeth Quackenbush
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Ulrich H von Andrian
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.)
| | - Markus Sperandio
- From the Walter Brendel Centre of Experimental Medicine, Munich, Germany (A.M., C.N., I.R., S.K., A.R.M.K., A.F., J.P., M.P., R.I., S.D., M.S.); Division of Neonatology, Hauner Children's University Hospital and Perinatal Centre, Ludwig Maximilians University, Munich, Germany (C.N., A.F., V.W., A.W.F.); Medizinische Klinik und Poliklinik I, Klinikum der Ludwig Maximilians Universität, Munich, Germany (J.P.); Max Planck Institute for Molecular Biomedicine, Münster, Germany (L.K., F.K.); Max PIanck Institute of Biochemistry, Department of Molecular Medicine, Martinsried, Germany (M.M.); Roche Inc, New York, NY (E.Q.); and Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA (U.H.v.A.).
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23
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Abstract
INTRODUCTION Platelets play a key role in primary hemostasis and are also intricately linked to secondary hemostasis. Investigation of platelet function in children, especially in neonates, is seriously challenged by the volumes required to perform the majority of platelet function tests and due to the lack of standardization of these tests for use in children. Areas covered: The present review summarizes developmental hemostasis with a focus on the differences in platelet adhesion, activation and aggregation, between preterm neonates, full-term neonates, during childhood and in adults. Some of the most widely used platelet function tests are presented, including novel tests requiring only a small blood volume. Expert commentary: Currently available platelet function tests are limited as regards to investigation of neonates due to difficulties in obtaining adequate blood volume, poor standardization, lack of reference intervals for neonates and children, and an incomplete understanding of the functional phenotype of neonatal platelets, especially preterm neonatal platelets.
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Affiliation(s)
- Anne-Mette Hvas
- a Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - Emmanuel J Favaloro
- b Department of Haematology , Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital , Westmead , Australia
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24
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Nowak-Göttl U, Limperger V, Kenet G, Degenhardt F, Arlt R, Domschikowski J, Clausnizer H, Liebsch J, Junker R, Steppat D. Developmental hemostasis: A lifespan from neonates and pregnancy to the young and elderly adult in a European white population. Blood Cells Mol Dis 2016; 67:2-13. [PMID: 28017497 DOI: 10.1016/j.bcmd.2016.11.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/27/2016] [Indexed: 11/29/2022]
Abstract
Absolute values of reference ranges for coagulation assays in humans vary within the entire lifespan and confirm the concept of developmental hemostasis. It is known that physiologic concentrations of coagulation factors (F) gradually increase over age: they are lower in premature infants as compared to full-term babies, healthy children or adults. Here we demonstrate in a cohort of 1011 blood donors and in a group of 193 healthy pregnant women, that the process of developmental hemostasis proceeds in adults. During the course of pregnancy F and activation markers steadily increase until delivery with a parallel decrease noticed for protein S. From adolescents, young adults to the elderly there is a further increase of F, reaching significance starting between 35 and 50years of age compared to younger subjects. Covering the entire lifespan FVIII and von-Willebrand-factor showed the lowest values in carriers of blood group "O". Apart from pregnancy differences related to gender, pill users, smoking habits or the presence of thrombophilic variants were reported. Laboratory test results should be compared to age-related reference intervals when hemostatic defects are suspected to avoid misclassifications as being "healthy", prone to "bleeding" or vice versa to "thrombosis".
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Affiliation(s)
- Ulrike Nowak-Göttl
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany.
| | - Verena Limperger
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Gili Kenet
- Pediatric Coagulation Service, National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Centre, Tel-Hashomer, Israel
| | - Frauke Degenhardt
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, Germany
| | - Roman Arlt
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Justus Domschikowski
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Hartmut Clausnizer
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Jürgen Liebsch
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Ralf Junker
- University Hospital Schleswig-Holstein, Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, Campus Kiel & Lübeck, Germany
| | - Dagmar Steppat
- Center of Blood Transfusion, University Hospital Schleswig Holstein, Kiel & Lübeck, Germany
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25
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Cowman J, Quinn N, Geoghegan S, Müllers S, Oglesby I, Byrne B, Somers M, Ralph A, Voisin B, Ricco AJ, Molloy EJ, Kenny D. Dynamic platelet function on von Willebrand factor is different in preterm neonates and full-term neonates: changes in neonatal platelet function. J Thromb Haemost 2016; 14:2027-2035. [PMID: 27416003 DOI: 10.1111/jth.13414] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 06/19/2016] [Indexed: 01/29/2023]
Abstract
Essentials It is unclear if platelet function differs between preterm and full-term neonates. Platelet behavior was characterized using a flow-based assay on von Willebrand Factor (VWF). Preterms had increased platelet interaction with VWF and glycoprotein Ibα expression. Platelets from preterm neonates behave differently on VWF compared to full-term neonates. SUMMARY Background Very low birth weight (VLBW) preterm neonates have an increased risk of hemorrhage-related morbidity and mortality as compared with their full-term counterparts. It is unclear whether platelet function differs between preterm and full-term neonates. This is partly because of the large volumes of blood required to perform standard platelet function tests, and the difficulty in obtaining such samples in neonates. Objectives This study was designed to characterize platelet behavior in neonates with a physiologic flow-based assay that quantifies platelet function in microliter volumes of blood under arterial shear. Methods Blood from VLBW preterm neonates of ≤ 32 weeks' gestation (n = 15) and full-term neonates (n = 13) was perfused under arterial shear over surface-immobilized von Willebrand factor (VWF). Platelet behavior was recorded by digital-image microscopy and analyzed. Surface expression of platelet glycoprotein (GP) Ibα and GPIIIa of VLBW preterm and full-term neonates was also measured. Results VLBW preterm neonates had increased numbers of platelets interacting with VWF, and increased GPIbα expression on the platelet surface. Despite the increased numbers of VWF interactions as reflected by flow-driven platelet translocation along the protein surface, no significant differences were observed in the numbers of platelets that adhered in a stationary fashion to VWF. Platelets from VLBW preterm neonates and those from full-term neonates behaved differently on VWF. Conclusions These differences in platelet function may contribute to the higher incidence of bleeding observed in VLBW preterm neonatal populations, or may represent a compensatory mechanism to counteract this risk of bleeding.
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Affiliation(s)
- J Cowman
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland
| | - N Quinn
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - S Geoghegan
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - S Müllers
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - I Oglesby
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland
| | - B Byrne
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland
| | - M Somers
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland
| | - A Ralph
- Irish Centre for High End Computing National University Ireland, Galway, Ireland
| | - B Voisin
- Irish Centre for High End Computing National University Ireland, Galway, Ireland
| | - A J Ricco
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland
| | - E J Molloy
- Department of Paediatrics, Trinity College Dublin, National Children's Hospital, Tallaght & Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - D Kenny
- Biomedical Diagnostics Institute, Royal College of Surgeons in Ireland and Dublin City University, Dublin, Ireland.
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26
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Sparger KA, Assmann SF, Granger S, Winston A, Christensen RD, Widness JA, Josephson C, Stowell SR, Saxonhouse M, Sola-Visner M. Platelet Transfusion Practices Among Very-Low-Birth-Weight Infants. JAMA Pediatr 2016; 170:687-94. [PMID: 27213618 PMCID: PMC6377279 DOI: 10.1001/jamapediatrics.2016.0507] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE Thrombocytopenia and intraventricular hemorrhage (IVH) are common among very-low-birth-weight (VLBW) infants. Survey results suggest that US neonatologists frequently administer platelet transfusions to VLBW infants with mild to moderate thrombocytopenia. OBJECTIVES To characterize platelet transfusion practices in US neonatal intensive care units (NICUs), to determine whether severity of illness influences platelet transfusion decisions, and to examine the association between platelet count (PCT) and the risk for IVH in the first 7 days of life. DESIGN, SETTING, AND PARTICIPANTS This multicenter, retrospective cohort study included 972 VLBW infants treated in 6 US NICUs, with admission dates from January 1, 2006, to December 31, 2007. Data were collected from all infants until NICU discharge or death (last day of data collected, December 4, 2008). Data were entered into the central database, cleaned, and analyzed from May 1, 2009, to February 11, 2016. INTERVENTION Platelet transfusion. MAIN OUTCOMES AND MEASURES Number of platelet transfusions and incidence of IVH. RESULTS Among the 972 VLBW infants (520 [53.5%] male; mean [SD] gestational age, 28.2 [2.9] weeks), 231 received 1002 platelet transfusions (mean [SD], 4.3 [6.0] per infant; range, 1-63 per infant). The pretransfusion PCT was at least 50 000/μL for 653 of 998 transfusions (65.4%) with this information. Two hundred eighty-one transfusions (28.0%) were given during the first 7 days of life. During that period, platelet transfusions were given on 35 of 53 days (66.0%) when the patient had a PCT less than 50 000/μL and on 203 of 436 days (46.6%) when the patient had a PCT of 50 000/μL to 99 000/μL. At least 1 marker of severe illness was present on 198 of 212 patient-days (93.4%) with thrombocytopenia (PCT, <100 000/μL) when a platelet transfusion was given compared with 113 of 190 patient-days (59.5%) with thrombocytopenia when no platelet transfusion was given. Thrombocytopenia was a risk factor for intraventricular hemorrhage during the first 7 days of life (hazard ratio, 2.17; 95% CI, 1.53-3.08; P < .001). However, no correlation was found between severity of thrombocytopenia and risk for IVH. After controlling for significant clinical factors and thrombocytopenia, platelet transfusions did not have a significant effect on the incidence of IVH (hazard ratio, 0.92; 95% CI, 0.49-1.73; P = .80). CONCLUSIONS AND RELEVANCE A large proportion of platelet transfusions were given to VLBW infants with PCT greater than 50 000/μL. Severity of illness influenced transfusion decisions. However, the severity of thrombocytopenia did not correlate with the risk for IVH, and platelet transfusions did not reduce this risk.
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Affiliation(s)
- Katherine A. Sparger
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, Massachusetts2Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Boston
| | - Susan F. Assmann
- Center for Epidemiological and Statistical Research, New England Research Institutes, Watertown, Massachusetts
| | - Suzanne Granger
- Center for Epidemiological and Statistical Research, New England Research Institutes, Watertown, Massachusetts
| | - Abigail Winston
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | | | | | - Cassandra Josephson
- Center for Transfusion and Cellular Therapies, Department of Pathology, Emory University, Atlanta, Georgia7Aflac Cancer Center and Blood Disorders, Department of Pediatrics, Emory University, Atlanta, Georgia
| | - Sean R. Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology, Emory University, Atlanta, Georgia7Aflac Cancer Center and Blood Disorders, Department of Pediatrics, Emory University, Atlanta, Georgia
| | | | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, Massachusetts
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Sola-Visner M, Bercovitz RS. Neonatal Platelet Transfusions and Future Areas of Research. Transfus Med Rev 2016; 30:183-8. [PMID: 27282660 DOI: 10.1016/j.tmrv.2016.05.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/05/2016] [Accepted: 05/23/2016] [Indexed: 12/17/2022]
Abstract
Thrombocytopenia affects approximately one fourth of neonates admitted to neonatal intensive care units, and prophylactic platelet transfusions are commonly administered to reduce bleeding risk. However, there are few evidence-based guidelines to inform clinicians' decision-making process. Developmental differences in hemostasis and differences in underlying disease processes make it difficult to apply platelet transfusion practices from other patient populations to neonates. Thrombocytopenia is a risk factor for common preterm complications such as intraventricular hemorrhage; however, a causal link has not been established, and platelet transfusions have not been shown to reduce risk of developing intraventricular hemorrhage. Platelet count frequently drives the decision of whether to transfuse platelets, although there is little evidence to demonstrate what a safe platelet nadir is in preterm neonates. Current clinical assays of platelet function often require large sample volumes and are not valid in the setting of thrombocytopenia; however, evaluation of platelet function and/or global hemostasis may aid in the identification of neonates who are at the highest risk of bleeding. Although platelets' primary role is in establishing hemostasis, platelets also carry pro- and antiangiogenic factors in their granules. Aberrant angiogenesis underpins common complications of prematurity including intraventricular hemorrhage and retinopathy of prematurity. In addition, platelets play an important role in host immune defenses. Infectious and inflammatory conditions such as sepsis and necrotizing enterocolitis are commonly associated with late-onset thrombocytopenia in neonates. Severity of thrombocytopenia is correlated with mortality risk. The nature of this association is unclear, but preclinical data suggest that thrombocytopenia contributes to mortality rather than simply being a proxy for disease severity. Neonates are a distinct patient population in whom thrombocytopenia is common. Their unique physiology and associated complications make the risks and benefits of platelet transfusions difficult to understand. The goal of this review was to highlight research areas that need to be addressed to better understand the risks and benefits of platelet transfusions in neonates. Specifically, it will be important to identify neonates at risk of bleeding who would benefit from a platelet transfusion and to determine whether platelet transfusions either abrogate or exacerbate common neonatal complications such as sepsis, chronic lung disease, necrotizing enterocolitis, and retinopathy of prematurity.
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Affiliation(s)
- Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Sidlik R, Strauss T, Morag I, Shenkman B, Tamarin I, Lubetsky A, Livnat T, Kenet G. Assessment of Functional Fibrinolysis in Cord Blood Using Modified Thromboelastography. Pediatr Blood Cancer 2016; 63:839-43. [PMID: 26749087 DOI: 10.1002/pbc.25865] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/10/2015] [Accepted: 11/13/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND The fibrinolytic system in newborns is immature and probably impaired. The aim of this study was to prospectively evaluate functional fibrinolytic capacity of newborn's cord blood using a new thromboelastometry (rotational thromboelastogram, ROTEM®) test. METHODS Infants born at Sheba Medical Center were studied prospectively. Cord blood was obtained immediately after clumping, and ROTEM parameters were assessed applying non-activated TEM (NATEM) assay with increasing concentration of tissue plasminogen activator (tPA, 0-200 U/ml). Baseline clotting time (CT), clot formation time (CFT), alpha angle, and maximum clot firmness (MCF) were compared among infants versus adults. Each infant's demographic information was prospectively followed up until discharge. RESULTS One hundred one newborns were tested. CT and CFT values were lower and alpha angles were higher among neonate's cord blood compared to adults (n = 23; P = 0.001, 0.03, and 0.02, respectively). The addition of tPA significantly shortened CT and CFT, and reduced alpha angles and MCF in both groups. The lysis index at 30 min (LI30) and lysis onset time (LOT) decreased significantly, and fibrinolysis was more rapid in the newborns. Hematocrit and platelet counts in neonates correlated with LI30 (P = 0.035 and 0.037, respectively) and LOT (P = 0.02) when higher tPA concentrations were used. ROTEM values were unrelated to the occurrence of postnatal complications. CONCLUSIONS This first report of functional fibrinolysis in cord blood demonstrated that neonatal fibrinolysis may be augmented as compared to adult values. Further studies are required to validate this test and assess its predictive value and clinical relevance.
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Affiliation(s)
- Rakefet Sidlik
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tzipora Strauss
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iris Morag
- Neonatology Department, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Shenkman
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ilia Tamarin
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Aharon Lubetsky
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Livnat
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Departments of Pediatrics, Thrombosis and the National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
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Cremer M, Sallmon H, Kling PJ, Bührer C, Dame C. Thrombocytopenia and platelet transfusion in the neonate. Semin Fetal Neonatal Med 2016; 21:10-8. [PMID: 26712568 DOI: 10.1016/j.siny.2015.11.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neonatal thrombocytopenia is widespread in preterm and term neonates admitted to neonatal intensive care units, with up to one-third of infants demonstrating platelet counts <150 × 10(9)/L. Thrombocytopenia may arise from maternal, placental or fetal/neonatal origins featuring decreased platelet production, increased consumption, or both mechanisms. Over the past years, innovations in managing neonatal thrombocytopenia were achieved from prospectively obtained clinical data on thrombocytopenia and bleeding events, animal studies on platelet life span and production rate and clinical use of fully automated measurement of reticulated platelets (immature platelet fraction). This review summarizes the pathophysiology of neonatal thrombocytopenia, current management including platelet transfusion thresholds and recent developments in megakaryopoietic agents. Furthermore, we propose a novel index score for bleeding risk in thrombocytopenic neonates to facilitate clinician's decision-making when to transfuse platelets.
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Affiliation(s)
- Malte Cremer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany.
| | - Hannes Sallmon
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
| | - Pamela J Kling
- Department of Pediatrics, University of Wisconsin - Madison, Madison, WI, USA
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
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Abstract
The various blood cell counts of neonates must be interpreted in accordance with high-quality reference intervals based on gestational and postnatal age. Using very large sample sizes, we generated neonatal reference intervals for each element of the complete blood count (CBC). Knowledge of whether a patient has CBC values that are too high (above the upper reference interval) or too low (below the lower reference interval) provides important insights into the specific disorder involved and in many instances suggests a treatment plan.
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Affiliation(s)
- Erick Henry
- Women and Newborn's Program, Intermountain Healthcare, 36 S. State Street, Salt Lake City, UT 84111, USA; The Institute for Healthcare Delivery Research, 36 S. State Street Salt Lake City, UT 84111, USA.
| | - Robert D Christensen
- Women and Newborn's Program, Intermountain Healthcare, 36 S. State Street, Salt Lake City, UT 84111, USA; Division of Neonatology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108 USA; Division of Hematology/Oncology, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108 USA
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31
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Abstract
There is significant world-wide variability in platelet transfusion thresholds used to transfuse thrombocytopenic neonates. A large multicenter randomized controlled trial comparing 2 different platelet transfusion thresholds in neonates is currently ongoing, and should provide data to guide transfusion practice. However, several studies have found that factors other than the degree of thrombocytopenia determine the bleeding risk. Thus, it will be important to develop better tests to assess primary hemostasis and bleeding risk in neonates.
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Abstract
Similarly to the development of the plasma coagulation system, which matures during the early weeks and months of life, age-dependent mechanisms and developmental changes influence platelet production and function in neonates. Platelet function testing on cord blood and peripheral blood demonstrates a generalized platelet hyporeactivity, during the first days of life. This reactivity reaches normal adult levels between the fifth and ninth day of life. The persistence of hyporeactivity after the tenth day of life might indeed suggest a platelet disorder.
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Affiliation(s)
- Antonio Del Vecchio
- Neonatal Intensive Care Unit, Di Venere Hospital, Via Ospedale Di Venere n.1, Bari 70131, Italy.
| | - Mario Motta
- Neonatology and Neonatal Intensive Care Unit, Children's Hospital of Brescia, Brescia, Italy
| | - Costantino Romagnoli
- Neonatal Intensive Care Unit, Division of Neonatology, Department of Pediatrics, Catholic University of the Sacred Heart, Rome, Italy
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Nowak-Göttl U, Limperger V, Bauer A, Kowalski D, Kenet G. Bleeding issues in neonates and infants – update 2015. Thromb Res 2015; 135 Suppl 1:S41-3. [DOI: 10.1016/s0049-3848(15)50440-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Andres O, Schulze H, Speer CP. Platelets in neonates: central mediators in haemostasis, antimicrobial defence and inflammation. Thromb Haemost 2014; 113:3-12. [PMID: 25185520 DOI: 10.1160/th14-05-0476] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/07/2014] [Indexed: 12/26/2022]
Abstract
Platelets are not only centrally involved in haemostasis, but also in antimicrobial defence and inflammation. Since evaluation of platelet physiology in the particular patient group of preterm and term neonatal infants is highly restricted for ethical reasons, there are hardly any data available in healthy and much less in extremely immature or ill neonates. By summarising current knowledge and addressing both platelet researchers and neonatologists, we describe neonatal platelet count and morphology, report on previous analyses of neonatal platelet function in primary haemostasis and provide insights into recent advances in platelet immunology that considerably impacts our clinical view on the critically ill neonatal infant. We conclude that neonatal platelets, originating from liver megakaryocytes, substantially differ from adult platelets and may play a pivotal role in the pathophysiology of neonatal sepsis or intraventricular haemorrhage, both complications which seriously augment perinatal morbidity and mortality.
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Affiliation(s)
- Oliver Andres
- Dr. med. Oliver Andres, University Children's Hospital Würzburg, Josef-Schneider-Straße 2, 97080 Würzburg, Germany, Tel.: +49 931 201 27728, Fax: +49 931 201 6027799, E-mail:
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35
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Haley KM, Recht M, McCarty OJ. Neonatal platelets: mediators of primary hemostasis in the developing hemostatic system. Pediatr Res 2014; 76:230-7. [PMID: 24941213 PMCID: PMC4348010 DOI: 10.1038/pr.2014.87] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/19/2014] [Indexed: 12/16/2022]
Abstract
The human hemostatic system is developmentally regulated, resulting in qualitative and quantitative differences in the mediators of primary and secondary hemostasis as well as fibrinolysis in neonates and infants. Although gestational age-related differences in coagulation factor levels occur, the existence of a unique neonatal platelet phenotype remains controversial. Complicated by difficulties in obtaining adequate neonatal blood volumes with which to perform functional assays, ambiguity surrounds the characterization of neonatal platelets. Thus, much of the current knowledge of neonatal platelet function has been based on studies from cord blood samples. Studies suggest that cord blood-derived platelets, as a surrogate for neonatal platelets, are hypofunctional when compared with adult platelets. This relative platelet dysfunction, combined with a propensity toward thrombocytopenia in the neonatal intensive care unit population, creates a clinical conundrum regarding the appropriate administration of platelet transfusions. This review provides an appraisal of the distinct functional phenotype of neonatal platelets. Neonatal platelet transfusion practices and the impact of the relatively hypofunctional neonatal platelet on those practices will be considered.
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Affiliation(s)
- Kristina M. Haley
- The Hemophilia Center, Oregon Health & Science University, Portland, OR, USA
| | - Michael Recht
- The Hemophilia Center, Oregon Health & Science University, Portland, OR, USA
| | - Owen J.T. McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, USA
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36
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Gunnink SF, Vlug R, Fijnvandraat K, van der Bom JG, Stanworth SJ, Lopriore E. Neonatal thrombocytopenia: etiology, management and outcome. Expert Rev Hematol 2014; 7:387-95. [PMID: 24665958 DOI: 10.1586/17474086.2014.902301] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Thrombocytopenia is a very common hematological abnormality found in newborns, especially in preterm neonates. Two subgroups can be distinguished: early thrombocytopenia, occurring within the first 72 hours of life, and late thrombocytopenia, occurring after the first 72 hours of life. Early thrombocytopenia is associated with intrauterine growth restriction, whereas late thrombocytopenia is caused mainly by sepsis and necrotizing enterocolitis (NEC). Platelet transfusions are the hallmark of the treatment of neonatal thrombocytopenia. Most of these transfusions are prophylactic, which means they are given in the absence of bleeding. However, the efficacy of these transfusions in preventing bleeding has never been proven. In addition, risks of platelet transfusion seem to be more pronounced in preterm neonates. Because of lack of data, platelet transfusion guidelines differ widely between countries. This review summarizes the current understanding of etiology and management of neonatal thrombocytopenia.
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Deschmann E, Sola-Visner M, Saxonhouse MA. Primary hemostasis in neonates with thrombocytopenia. J Pediatr 2014; 164:167-72. [PMID: 24094764 DOI: 10.1016/j.jpeds.2013.08.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 08/01/2013] [Accepted: 08/20/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the relationship between platelet counts and the platelet function analyzer-100 closure times (CTs) in neonates with thrombocytopenia, and to determine what other factors significantly affect CTs. STUDY DESIGN In a single institution prospective cross-sectional study, blood samples from neonates with platelet counts <150 × 10(9)/L were tested on the platelet function analyzer-100 with CT-collagen/epinephrine (CT-Epi) and CT-collagen/adenosine diphosphate (CT-ADP) cartridges. RESULTS The mean platelet count was 95 ± 28 × 10(9)/L for 48 infants with a mean gestational age 30.9 ± 5.3 weeks and median postnatal age of 5 (3-18) days. No association was evident between CT-Epi and platelet count. However, the CT-ADP was prolonged in many (but not all) infants with platelet counts <90 × 10(9)/L. Among infants <32 weeks gestational age, we found a moderate negative correlation between CT-ADP and platelet count (r = -0.54, P = .0045). The negative correlation was strongest in infants <32 weeks and <10 days old (r = -0.8, P = .0017). Other variables examined (hematocrit, infection, Score of Neonatal Acute Physiology II) did not have a significant effect on CT-ADP in a linear regression model. CONCLUSIONS Platelet counts <90 × 10(9)/L are associated with prolonged CT-ADP times in some but not all infants. Gestational and postnatal age-related differences in platelet function account for some of this variability. The predictive value of CT-ADP on neonatal bleeding risk remains to be studied.
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Affiliation(s)
- Emoke Deschmann
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA; Division of Neonatology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Matthew A Saxonhouse
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL; Department of Pediatrics, Levine Children's Hospital/Jeff Gordon Children's Hospital, Carolinas Healthcare System, Concord, NC
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Zisk JL, Mackley A, Clearly G, Chang E, Christensen RD, Paul DA. Transfusing neonates based on platelet count vs. platelet mass: A randomized feasibility-pilot study. Platelets 2013; 25:513-6. [DOI: 10.3109/09537104.2013.843072] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Coen RW. Preventing germinal matrix layer rupture and intraventricular hemorrhage. Front Pediatr 2013; 1:22. [PMID: 24400268 PMCID: PMC3864188 DOI: 10.3389/fped.2013.00022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 08/18/2013] [Indexed: 11/13/2022] Open
Abstract
The etiology of intraventricular hemorrhage (IVH) in extremely low birth weight preterm infants is multifactorial with circulatory instability and hemostasis being preeminent. This study sought to determine if the germinal matrix layer remained intact when platelets were above 200 × 10(9)/L, a near normal level, and fell below that when IVH occurred. This was a retrospective study of platelets and head ultrasounds (HUS) in infants 23-28 weeks gestation. Analyses were descriptive, one way analysis of variance, Pearson Chi-square tests, and t-tests. Platelet counts and HUS were linked in 114 infants during the first 3 days when 90% of IVHs occur. Mean platelet levels were >200 × 10(9)/L in 68% of infant 23-24 weeks gestation and 78% of those 25-26 weeks when there were no IVHs. These findings, if confirmed, suggest that improving hemostasis in high risk preterm infants by keeping platelet levels >200 × 10(9)/L may maintain the integrity of the germinal matrix layer and prevent IVHs.
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Affiliation(s)
- Ronald W Coen
- Department of Pediatrics, St. Luke's Regional Medical Center , Boise, ID , USA
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40
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Ferrer-Marin F, Stanworth S, Josephson C, Sola-Visner M. Distinct differences in platelet production and function between neonates and adults: implications for platelet transfusion practice. Transfusion 2013; 53:2814-21; quiz 2813. [PMID: 23889476 DOI: 10.1111/trf.12343] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia is a common problem among sick neonates admitted to the neonatal intensive care unit. Among neonates, preterm infants are the subgroup at highest risk for thrombocytopenia and hemorrhage, which is frequently intracranial. Although there is no evidence of a relationship between platelet (PLT) count and occurrence of major hemorrhage, preterm infants are commonly transfused prophylactically when PLT counts fall below an arbitrary limit, and this threshold is usually higher than for older infants or adults. This liberal practice has been influenced by the observation that, in vitro, neonatal PLTs are hyporeactive in response to multiple agonists. However, full-term infants exhibit normal to increased primary hemostasis due to factors in neonatal blood that enhance the PLT-vessel wall interaction. Additionally, cardiorespiratory problems are considered the main etiologic factors in the development of neonatal intraventricular hemorrhage. In this review, we will discuss the developmental differences that exist in regard to PLT production and function, as well as in primary hemostasis in preterm and term neonates, and the implications of these developmental differences to transfusion medicine. PLT transfusions are not exempt of risk, and a better understanding of the PLT function and the hemostatic profile of premature infants and their changes over time and in response to illness is the starting point to design randomized controlled trials to define optimal use of PLT transfusions in premature neonates. Without these future trials, the marked disparities in PLT transfusion practice in neonates between hospitals and countries will remain over time.
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Affiliation(s)
- Francisca Ferrer-Marin
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales-Meseguer, Centro de Hemodonacion, Murcia, Spain; Department of Haematology/Transfusion Medicine, NHS Blood & Transplant/Oxford University Hospitals NHS Trust, Oxford, UK; Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia; Division of Newborn Medicine, Children's Hospital Boston, Boston, Massachusetts
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41
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Del Vecchio A, Motta M, Radicioni M, Christensen RD. A consistent approach to platelet transfusion in the NICU. J Matern Fetal Neonatal Med 2013; 25:93-6. [PMID: 23025779 DOI: 10.3109/14767058.2012.716985] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Platelet transfusions are the principal means of treating thrombocytopenia in neonatal intensive care units (NICUs), and are generally used as treatment of thrombocytopenic neonates who have active bleeding and as prophylactic administration in thrombocytopenic neonates who do not have hemorrhage but appear to be at high risk for bleeding. In this article, we summarize the rationale, benefits and risks of platelet transfusions in neonates. We review the importance of choosing the best product available for platelet transfusion, and we emphasize the importance of adopting and adhering to transfusion guidelines.
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Affiliation(s)
- Antonio Del Vecchio
- Division of Neonatology, Neonatal Intensive Care Unit, Di Venere Hospital, Bari, Italy.
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Christensen RD, Henry E, Del Vecchio A. Thrombocytosis and thrombocytopenia in the NICU: incidence, mechanisms and treatments. J Matern Fetal Neonatal Med 2013; 25 Suppl 4:15-7. [PMID: 22958004 DOI: 10.3109/14767058.2012.715027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Quantitative and qualitative platelet abnormalities of neonates must be defined using evidence-based reference ranges, constructed according to gestational and postnatal age. METHODS Platelet counts, and demographic and outcome data, were obtained from neonates in the Intermountain Healthcare system in the western USA and template bleeding times were determined from neonates in Italy. RESULTS Reference ranges were constructed by excluding values from neonates with diagnoses associated with abnormal platelet counts (small for gestational age (SGA), pregnancy-induced hypertension (PIH), infection and necrotizing enterocolitis (NEC)). Values remaining in the database after excluding these diagnoses were organized into 5th to 95th percentile ranges. At 23-25 weeks gestation, thrombocytopenia (<5th percentile) was defined by a platelet count <100,000/µl. Severe thrombocytopenia (platelet count <50,000/µl) occurred in 2.4% of neonatal intensive care unit (NICU) admissions and was largely due to acquired consumptive causes (bacterial and fungal sepsis, NEC and extracorporeal membrane oxygenation). No correlation was found between platelet count and subsequent central nervous system (CNS), pulmonary or gastrointestinal (GI) bleeding. The mortality rate did not correlate with the lowest platelet count but was proportionate to the number of platelet transfusions received. Platelet transfusions, administered according to guidelines, were given to 7% of NICU admissions, but a change in the guidelines from "count-based" to "mass-based" was associated with a reduction to 4%, with no increase in CNS, pulmonary, GI or cutaneous haemorrhage. Bleeding times were twice as long in neonates <33 weeks gestation as in term neonates, and shortened to term values by day of life ten. CONCLUSIONS When reference ranges for platelets, appropriate to gestational and postnatal ages, are used, more uniformity occurs in definitions. This uniformity will foster consistency in diagnosis, treatment and outcomes-reporting.
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Affiliation(s)
- Robert D Christensen
- Women and Newborns Program, Intermountain Healthcare, Salt Lake City, Utah, UT 84403, USA.
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Abstract
Abstract
Survival rates for infants born prematurely have improved significantly, in part due to better supportive care such as RBC transfusion. The role of platelet transfusions in neonates is more controversial. Neonatal thrombocytopenia is common in premature infants. The primary causal factors are intrauterine growth restriction/maternal hypertension, in which the infant presents with thrombocytopenia soon after birth, and sepsis/necrotizing enterocolitis, which are the common morbidities associated with thrombocytopenia in neonates > 72 hours of age. There is no evidence of a relationship between platelet count and occurrence of major hemorrhage, and cardiorespiratory problems are considered the main etiological factors in the development of intraventricular and periventricular hemorrhage in the neonatal period. Platelet transfusions are used commonly as prophylaxis in premature neonates with thrombocytopenia. However, there is widespread variation in the pretransfusion thresholds for platelet count and evidence of marked disparities in platelet transfusion practice between hospitals and countries. Platelet transfusions are biological agents and as such are associated with risks. Unlike other patient groups, specifically patients with hematological malignancies, there have been no recent clinical trials undertaken comparing different thresholds for platelet transfusion in premature neonates. Therefore, there is no evidence base with which to inform safe and effective practice for prophylactic platelet transfusions. There is a need for randomized controlled trials to define the optimal use of platelet transfusions in premature neonates, who at present are transfused heavily with platelets.
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Platelets in the neonatal period: developmental differences in platelet production, function, and hemostasis and the potential impact of therapies. Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.506.3798532] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Thrombocytopenia is a common problem among sick neonates admitted to the neonatal intensive care unit. Frequently, platelet transfusions are given to thrombocytopenic infants in an attempt to decrease the incidence or severity of hemorrhage, which is often intracranial. Whereas there is very limited evidence to guide platelet transfusion practices in this population, preterm infants in the first week of life (the highest risk period for bleeding) are nearly universally transfused at higher platelet counts than older infants or children. To a large extent, this practice has been influenced by the observation that neonatal platelets are hyporeactive in response to multiple agonists in vitro, although full-term infants exhibit normal to increased primary hemostasis. This apparently paradoxical finding is due to factors in the neonatal blood that enhance the platelet-vessel wall interaction and counteract the platelet hyporeactivity. Relatively few studies have evaluated the platelet function and primary hemostasis of preterm infants, the subset of neonates at highest risk of bleeding and those most frequently transfused. Current understanding of platelet production and function in preterm and full-term neonates, how these factors affect their response to thrombocytopenia and their primary hemostasis, and the implications of these developmental differences to transfusion medicine are reviewed herein.
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Abstract
Abstract
The maturation and postnatal development of the human coagulation system was first studied and described more than 20 years ago. These older studies, supported by more recent data, confirm the significant and important differences in the physiology of coagulation and fibrinolysis in neonates and young children compared with older children and adults. Subsequently, significant differences were also described in the physiology of primary hemostasis and in global in vitro tests for hemostasis. These differences, which mostly reflect the immaturity of the neonatal hemostasis system, are functionally balanced. Healthy neonates show no signs of easy bruising or other bleeding diathesis and no increased tendency to thrombosis for any given stimulus compared with adults. Systemic diseases may affect hemostasis, predisposing ill neonates to increased hemorrhagic or thrombotic complications. The immaturity of the hemostasis system in preterm and very-low-birth-weight neonates may contribute to a higher risk for intraventricular hemorrhage. Therapies targeting the hemostasis system can be effective for preventing and treating these events. The concept of “neonatal coagulopathy” has an important impact on both the diagnosis and management of hemorrhagic or thrombotic events in neonates. For diagnosis of hemostasis disorders, diagnostic laboratories processing pediatric samples should use age-, analyzer-, and reagent-appropriate reference ranges. Age-specific guidelines should be followed for the management of neonates with hemostatic disorders.
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Muthukumar P, Venkatesh V, Curley A, Kahan BC, Choo L, Ballard S, Clarke P, Watts T, Roberts I, Stanworth S. Severe thrombocytopenia and patterns of bleeding in neonates: results from a prospective observational study and implications for use of platelet transfusions. Transfus Med 2012; 22:338-43. [PMID: 22738179 DOI: 10.1111/j.1365-3148.2012.01171.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 05/29/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe patterns of clinical bleeding in neonates with severe thrombocytopenia (ST and platelet count <60 × 10(9) L(-1)), and to investigate the factors related to bleeding. STUDY DESIGN Seven tertiary-level neonatal units enrolled neonates (n = 169) with ST. Data were collected prospectively on all clinically apparent haemorrhages. Relationships between bleeding, platelet count and baseline characteristics were explored through regression analysis. RESULTS Bleeding was recorded in most neonates with ST (138/169; 82%), including 123 neonates with minor bleeding and 15 neonates with major bleeding. The most common sites of minor bleeding were from the renal tract (haematuria 40%), endotracheal tube (21%), nasogastric tube (10%) and skin (15%). Gestational age <34 weeks, development of ST within 10 days of birth and necrotizing enterocolitis were the strongest predictors for an increased number of bleeding events. For neonates with ST, a lower platelet count was not a strong predictor of increased bleeding. CONCLUSIONS The majority of neonates with ST bleed, although most episodes are minor. These findings establish the importance of clinical factors for bleeding risk, rather than minimum platelet count. Further studies should assess the clinical significance of different types of minor bleed for neonatal outcomes, the predictive value of minor bleeding for major bleeding and the role of platelet transfusions in preventing bleeding.
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Affiliation(s)
- P Muthukumar
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
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Christensen RD, Sheffield MJ, Lambert DK, Baer VL. Effect of therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy on platelet function. Neonatology 2012; 101:91-4. [PMID: 21934334 DOI: 10.1159/000329818] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 05/31/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Platelet dysfunction has been described in adults during hypothermia. We sought to determine whether it also occurs in neonates. METHODS We measured bleeding times and PFA-100 (platelet function analyzer) times in 10 neonates with hypoxic-ischemic encephalopathy during and after head cooling. RESULTS The 10 neonates were born at 38.2 ± 1.6 weeks' gestation (mean ± SD), with birth weights of 3,222 ± 746 g, pH 6.79 ± 0.17, base excess -25 ± 8, and 10-min Apgar 4 ± 2. Cooling was instituted 111 min (range: 66-180) after birth and continued 72 h. Bleeding times before cooling averaged 170 s (95% CI: 100-240). These lengthened during hypothermia, averaging 410 s (p = 0.000) and shortened after rewarming (p = 0.000). PFA-100 times were similar: prolongation during cooling and normalization after rewarming. Six neonates had clinical bleeding problems in the first 24 h of cooling, but were managed successfully, and no intracranial hemorrhages were identified. CONCLUSION Defective platelet plug formation occurs during therapeutic hypothermia of neonates in a manner similar to that described in adults. Platelet impairment can be severe, but rapidly improves after rewarming.
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Affiliation(s)
- Robert D Christensen
- Department of Women and Newborns, Intermountain Healthcare, Salt Lake City, Utah 84403, USA. rdchris4 @ ihc.com
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Strauss T, Sidlik-Muskatel R, Kenet G. Developmental hemostasis: primary hemostasis and evaluation of platelet function in neonates. Semin Fetal Neonatal Med 2011; 16:301-4. [PMID: 21810548 DOI: 10.1016/j.siny.2011.07.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hemostasis is a dynamic process and physiologic concentrations of coagulation proteins gradually increase with gestational age. Nevertheless, the risk for bleeding in term neonates is counterbalanced by the protective effects of physiologic deficiencies of the inhibitors of coagulation. Although laboratory diagnosis of coagulation disorders in infants may be difficult to establish, due to the need to adapt all assays for small amounts of blood and the age-related interpretation required for test results - evaluation of infants with secondary hemostatic defects is quite feasible, whereas laboratory assessment of primary hemostasis in neonates remains a challenge. While platelet number and volume are similar in neonates as compared to adult values, neonatal platelets certainly exhibit hyporesponsiveness. Analysis of platelet function may include aggregation studies or flow cytometry assays, using fluorescence-stained monoclonal antibodies against platelet membranes and cellular antigens. Data on platelet function in correlation with gestational age are scarce and the duration of platelet hyporeactivity and its clinical significance have not yet been completely elucidated. Whole-blood-based platelet function assays have shown in neonates as well as in premature infants progressive improvement of clot formation with gestational age. This article reviews platelet function, assessed by various techniques, and its development in the premature as well as healthy term neonate.
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Affiliation(s)
- T Strauss
- Neonatology and Pediatric Departments of the Safra Children's Hospital, Tel Hashomer, Israel
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Del Vecchio A, Motta M. Evidence-based platelet transfusion recommendations in neonates. J Matern Fetal Neonatal Med 2011; 24 Suppl 1:38-40. [DOI: 10.3109/14767058.2011.607577] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Ductal closure in neonates: a developmental perspective on platelet-endothelial interactions. Blood Coagul Fibrinolysis 2011; 22:242-4. [PMID: 21455036 DOI: 10.1097/mbc.0b013e328344c5ed] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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