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Billion E, Ghattas S, Jarreau PH, Irmesi R, Ndoudi Likoho B, Patkai J, Zana-Taieb E, Torchin H. Lowering platelet-count threshold for transfusion in preterm neonates decreases the number of transfusions without increasing severe hemorrhage events. Eur J Pediatr 2024:10.1007/s00431-024-05709-x. [PMID: 39120698 DOI: 10.1007/s00431-024-05709-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024]
Abstract
Thrombocytopenia is common in preterm neonates and can be associated with hemorrhage. Most platelet transfusions are prophylactic. Previously, higher platelet-count thresholds were recommended for neonates, but this recommendation has been questioned in recent studies. In the PlaNeT2 trial, mortality and serious bleeding were more frequent in neonates with the highest platelet-count threshold than in others. Following this trial, we changed our platelet transfusion practice by lowering the platelet-count threshold for prophylactic transfusion from 50,000 to 25,000/mm3. We conducted a before-after retrospective cohort study to quantify the frequency of platelet transfusions and assess the new protocol by analyzing death and serious hemorrhage events. This retrospective monocentric study included neonates born before 37 weeks of gestation with platelet count < 150,000/mm3 during the 2 years preceding the new platelet transfusion protocol (high prophylactic transfusion threshold, 50,000/mm3) and during the 2 years after the new platelet transfusion protocol (low prophylactic transfusion threshold, 25,000/mm3). The primary outcome was the proportion of neonates receiving at least one platelet transfusion in both groups. We also compared the proportion of deaths and severe hemorrhage events. A total of 707 neonates with thrombocytopenia were identified. In the high-threshold group, 99/360 (27.5%) received at least one platelet transfusion as compared with 56/347 (16.1%) in the low-threshold group (p < 0.001). The groups did not differ in proportion of deaths or severe hemorrhage events. CONCLUSIONS A reduced platelet-count threshold for transfusion allowed for a significant reduction in the number of platelet transfusions without increasing severe hemorrhage events. WHAT IS KNOWN • A recent randomized trial suggested that restrictive platelet-count thresholds for platelet transfusion could be beneficial for preterm neonates. WHAT IS NEW • On lowering the platelet-count threshold for transfusion from 50,000 to 25,000/mm3, the number of transfusions significantly decreased without increasing severe hemorrhage events in a neonatal intensive care unit.
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Affiliation(s)
- Elodie Billion
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France.
- Réanimation Néonatale, Hôpital Femme Mère Enfant, 59 Bd Pinel, 69500, Bron, France.
| | - Souad Ghattas
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
| | - Pierre-Henri Jarreau
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, 75004, Paris, France
| | - Roberta Irmesi
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
| | - Bellaure Ndoudi Likoho
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
| | - Juliana Patkai
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
| | - Elodie Zana-Taieb
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
- Université Paris Cité, Inserm U955, Paris, France
| | - Heloise Torchin
- Department of Neonatal Medicine of Port-Royal, Cochin Hospital, FHU PREMA, AP-HP Centre, Université Paris Cité, 75014, Paris, France
- CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRAE, Université Paris Cité, 75004, Paris, France
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2
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Gilmore LE, Chou ST, Ghavam S, Thom CS. Consensus transfusion guidelines for a large neonatal intensive care network. Transfusion 2024; 64:1562-1569. [PMID: 38884350 DOI: 10.1111/trf.17914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 04/30/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Lindsay E Gilmore
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stella T Chou
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sarvin Ghavam
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher S Thom
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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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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Sokou R, Mantzios P, Tsantes AG, Parastatidou S, Ioakeimidis G, Lampridou M, Kokoris S, Iacovidou N, Houhoula D, Vaiopoulos AG, Piovani D, Bonovas S, Tsantes AE, Konstantinidi A. Assessment of hemostatic profile in neonates with necrotizing enterocolitis using Rotational Thromboelastometry (ROTEM). Pediatr Res 2024; 95:1596-1602. [PMID: 38092966 DOI: 10.1038/s41390-023-02958-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/16/2023] [Accepted: 11/27/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND This study aimed to explore the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and to investigate if ROTEM parameters have the capacity to play a role in the differentiation of NEC from sepsis at the disease onset. METHODS This observational study included 62 neonates (mean gestational age 31.6 weeks and mean birth weight 1620g) hospitalized in a neonatal intensive care unit. The neonates were categorized in three groups: neonates with NEC (Bell stage II and above), neonates with sepsis and healthy neonates and they were matched 1:1:1 with regards to gestational age, delivery mode, and sex. Clinical, laboratory data as well as measurements of ROTEM parameters at disease onset were recorded. RESULTS ROTEM parameters differed between neonates with NEC and neonates with sepsis, indicating that NEC results in accelerated clot formation and higher clot strength compared to sepsis. The EXTEM CFT and A10 parameters demonstrated the highest diagnostic performance for NEC in terms of discrimination between NEC and sepsis (AUC, 0.997; 95% CI: 0.991-1.000 and 0.973; 95% CI: 0.932-1.000, respectively). CONCLUSIONS Neonates with NEC manifested accelerated clot formation and higher clot strength compared to septic and healthy neonates, as these were expressed by ROTEM parameters. IMPACT This work reports data on the hemostatic profile of neonates with necrotizing enterocolitis (NEC) using Rotational Thromboelastometry (ROTEM) and the capacity of ROTEM parameters in differentiating of NEC from sepsis at the disease onset. Neonates with NEC present acceleration of coagulation and exhibit a hypercoagulable profile, as this is expressed by ROTEM parameters, in comparison to septic and healthy neonates. ROTEM parameters demonstrated a good diagnostic capacity in differentiating NEC from sepsis at the disease onset.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | - Petros Mantzios
- Department of Internal Medicine, General Hospital of Eastern Achaia, Aigio, Greece
| | - Andreas G Tsantes
- Microbiology Department, "Saint Savvas" Oncology Hospital, Athens, Greece
| | - Stavroula Parastatidou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Georgios Ioakeimidis
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Maria Lampridou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece
| | - Styliani Kokoris
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Dimitra Houhoula
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristeidis G Vaiopoulos
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Bahr TM, Snow GL, Christensen TR, Davenport P, Henry E, Tweddell SM, Ilstrup SJ, Yoder BA, Ohls RK, Sola-Visner MC, Christensen RD. Can Red Blood Cell and Platelet Transfusions Have a Pathogenic Role in Bronchopulmonary Dysplasia? J Pediatr 2024; 265:113836. [PMID: 37992802 DOI: 10.1016/j.jpeds.2023.113836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE To evaluate whether transfusions in infants born preterm contribute to the pathogenesis of bronchopulmonary dysplasia (BPD). STUDY DESIGN We conducted a multihospital, retrospective study seeking associations between red blood cell or platelet transfusions and BPD. We tabulated all transfusions administered from January 2018 through December 2022 to infants born ≤29 weeks or <1000 g until 36 weeks postmenstrual age and compared those with BPD grade. We performed a sensitivity analysis to assess the possibility of a causal relationship. We then determined whether each transfusion was compliant with restrictive guidelines, and we estimated effects fewer transfusions might have on future BPD incidence. RESULTS Eighty-four infants did not develop BPD and 595 did; 352 developed grade 1 (mild), 193 grade 2 (moderate), and 50 grade 3 (severe). Transfusions were given at <36 weeks to 7% of those who did not develop BPD, 46% who did, and 98% who developed severe BPD. For every transfusion the odds of developing BPD increased by a factor of 2.27 (95% CI, 1.59-3.68; P < .001). Sensitivity analyses suggested that transfusions might contribute to BPD. Fifty-seven percent of red blood cell transfusions and 68% of platelet transfusions were noncompliant with new restrictive guidelines. Modeling predicted that complying with restrictive guidelines could reduce the transfusion rate by 20%-30% and the moderate to severe BPD rate by ∼4%-6%. CONCLUSIONS Transfusions were associated with BPD incidence and severity. Lowering transfusion rates to comply with current restrictive guidelines might result in a small but meaningful reduction in BPD rates.
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Affiliation(s)
- Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT.
| | | | - Thomas R Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Erick Henry
- Department of Neonatology, Intermountain Health, Murray, UT
| | - Sarah M Tweddell
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Sarah J Ilstrup
- Transfusion Services and Department of Pathology, Intermountain Health, Murray, UT
| | - Bradley A Yoder
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Martha C Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT; Department of Neonatology, Intermountain Health, Murray, UT
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6
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Davenport PE, Wood TR, Heagerty PJ, Sola-Visner MC, Juul SE, Patel RM. Platelet Transfusion and Death or Neurodevelopmental Impairment in Children Born Extremely Preterm. JAMA Netw Open 2024; 7:e2352394. [PMID: 38261320 PMCID: PMC10807258 DOI: 10.1001/jamanetworkopen.2023.52394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/30/2023] [Indexed: 01/24/2024] Open
Abstract
Importance Infants born extremely preterm receive transfusions at higher platelet count thresholds than older children and adults due to concerns for intracranial hemorrhage. A recent randomized trial comparing 2 platelet transfusion thresholds showed the higher threshold was associated with increased risk of long-term adverse neurodevelopmental outcomes. Objective To evaluate the association of platelet transfusion exposure with death and severe neurodevelopmental impairment (NDI) at 2 years' corrected age in a cohort of infants born extremely preterm. Design, Setting, and Participants An observational cohort study and secondary analysis of the Preterm Erythropoietin Neuroprotection Trial, a randomized, placebo-controlled clinical trial of erythropoietin neuroprotection in neonates born extremely preterm, was conducted in 30 neonatal intensive care units in the US from December 1, 2013, to September 31, 2016. This analysis included 819 infants born extremely preterm at 24 to 27 completed weeks of gestation who had a documented outcome (death or neurodevelopmental assessment). Analysis was performed in April 2023. Exposures Any platelet transfusion during neonatal intensive care unit hospitalization. Main Outcomes and Measures The primary composite outcome was death or severe NDI evaluated at 2 years' corrected age using the Bayley Scales of Infant Development-Third Edition (BSID-III) and the Gross Motor Function Classification System and was defined as the presence of severe cerebral palsy or a BSID-III composite motor or cognitive score 2 SDs below the mean. Confounding by indication for platelet transfusion was addressed with covariate adjustment and propensity score methods. Results Of the 819 infants included in the analysis (429 [52.4%] male; mean [SD] gestational age, 25.5 [1.1] weeks), 245 (30.0%) received at least 1 platelet transfusion during their initial hospitalization. The primary outcome occurred in 46.5% (114 of 245) of infants exposed to a platelet transfusion and 13.9% (80 of 574) of nonexposed infants with a corresponding odds ratio of 2.43 (95% CI, 1.24-4.76), adjusted for propensity score, gestational age at birth, and trial treatment group. The individual components of death and severe NDI were directionally consistent with the overall composite outcome. Conclusions and Relevance The findings of this study suggest that platelet transfusion in infants born extremely preterm may be associated with an increased risk of death or severe NDI at 2 years' corrected age, although the possibility of residual confounding by indication cannot be excluded.
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Affiliation(s)
| | - Thomas R. Wood
- Division of Neonatology, University of Washington, Seattle
- Institute on Human Development and Disability, University of Washington, Seattle
| | | | | | - Sandra E. Juul
- Division of Neonatology, University of Washington, Seattle
- Institute on Human Development and Disability, University of Washington, Seattle
| | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine and Childrens Healthcare of Atlanta, Atlanta, Georgia
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7
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Christensen RD, Bahr TM, Davenport P, Sola-Visner MC, Kelley WE, Ilstrup SJ, Ohls RK. Neonatal Thrombocytopenia: Factors Associated With the Platelet Count Increment Following Platelet Transfusion. J Pediatr 2023; 263:113666. [PMID: 37572863 DOI: 10.1016/j.jpeds.2023.113666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/06/2023] [Accepted: 08/06/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVE To understand better those factors relevant to the increment of rise in platelet count following a platelet transfusion among thrombocytopenic neonates. STUDY DESIGN We reviewed all platelet transfusions over 6 years in our multi-neonatal intensive care unit system. For every platelet transfusion in 8 neonatal centers we recorded: (1) platelet count before and after transfusion; (2) time between completing the transfusion and follow-up count; (3) transfusion volume (mL/kg); (4) platelet storage time; (5) sex and age of platelet donor; (6) gestational age at birth and postnatal age at transfusion; and magnitude of rise as related to (7) pre-transfusion platelet count, (8) method of enhancing transfusion safety (irradiation vs pathogen reduction), (9) cause of thrombocytopenia, and (10) donor/recipient ABO group. RESULTS We evaluated 1797 platelet transfusions administered to 605 neonates (median one/recipient, mean 3, and range 1-52). The increment was not associated with gestational age at birth, postnatal age at transfusion, or donor sex or age. The rise was marginally lower: (1) with consumptive vs hypoproductive thrombocytopenia (P < .001); (2) after pathogen reduction (P < .01); (3) after transfusing platelets with a longer storage time (P < .001); and (4) among group O neonates receiving platelets from non-group O donors (P < .001). Eighty-seven neonates had severe thrombocytopenia (<20 000/μL). Among these infants, poor increments and death were associated with the cause of the thrombocytopenia. CONCLUSION The magnitude of post-transfusion rise was unaffected by most variables we studied. However, the increment was lower in neonates with consumptive thrombocytopenia, after pathogen reduction, with longer platelet storage times, and when not ABO matched.
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Affiliation(s)
- Robert D Christensen
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT; Obstetric and Neonatal Operations, Intermountain Health, Murray, UT.
| | - Timothy M Bahr
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT; Obstetric and Neonatal Operations, Intermountain Health, Murray, UT
| | - Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Martha C Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Walter E Kelley
- Blood Transfusion Services, American Red Cross, Salt Lake City, UT
| | - Sarah J Ilstrup
- Intermountain Health Transfusion Services and Department of Pathology, Intermountain Medical Center, Murray, UT
| | - Robin K Ohls
- Division of Neonatology, Department of Pediatrics, University of Utah Health, Salt Lake City, UT
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Wei J, Meng Z, Li Z, Dang D, Wu H. New insights into intestinal macrophages in necrotizing enterocolitis: the multi-functional role and promising therapeutic application. Front Immunol 2023; 14:1261010. [PMID: 37841247 PMCID: PMC10568316 DOI: 10.3389/fimmu.2023.1261010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is an inflammatory intestinal disease that profoundly affects preterm infants. Currently, the pathogenesis of NEC remains controversial, resulting in limited treatment strategies. The preterm infants are thought to be susceptible to gut inflammatory disorders because of their immature immune system. In early life, intestinal macrophages (IMφs), crucial components of innate immunity, demonstrate functional plasticity and diversity in intestinal development, resistance to pathogens, maintenance of the intestinal barrier, and regulation of gut microbiota. When the stimulations of environmental, dietary, and bacterial factors interrupt the homeostatic processes of IMφs, they will lead to intestinal disease, such as NEC. This review focuses on the IMφs related pathogenesis in NEC, discusses the multi-functional roles and relevant molecular mechanisms of IMφs in preterm infants, and explores promising therapeutic application for NEC.
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Affiliation(s)
- Jiaqi Wei
- Department of Neonatology, First Hospital of Jilin University, Changchun, China
| | - Zhaoli Meng
- Department of Translational Medicine Research Institute, First Hospital of Jilin University, Changchun, China
| | - Zhenyu Li
- Department of Neonatology, First Hospital of Jilin University, Changchun, China
| | - Dan Dang
- Department of Neonatology, First Hospital of Jilin University, Changchun, China
| | - Hui Wu
- Department of Neonatology, First Hospital of Jilin University, Changchun, China
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9
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Moore CM, D'Amore A, Fustolo-Gunnink S, Hudson C, Newton A, Santamaria BL, Deary A, Hodge R, Hopkins V, Mora A, Llewelyn C, Venkatesh V, Khan R, Willoughby K, Onland W, Fijnvandraat K, New HV, Clarke P, Lopriore E, Watts T, Stanworth S, Curley A. Two-year outcomes following a randomised platelet transfusion trial in preterm infants. Arch Dis Child Fetal Neonatal Ed 2023; 108:452-457. [PMID: 36810309 PMCID: PMC10447411 DOI: 10.1136/archdischild-2022-324915] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Assess mortality and neurodevelopmental outcomes at 2 years of corrected age in children who participated in the PlaNeT-2/MATISSE (Platelets for Neonatal Transfusion - 2/Management of Thrombocytopenia in Special Subgroup) study, which reported that a higher platelet transfusion threshold was associated with significantly increased mortality or major bleeding compared to a lower one. DESIGN Randomised clinical trial, enrolling from June 2011 to August 2017. Follow-up was complete by January 2020. Caregivers were not blinded; however, outcome assessors were blinded to treatment group. SETTING 43 level II/III/IV neonatal intensive care units (NICUs) across UK, Netherlands and Ireland. PATIENTS 660 infants born at less than 34 weeks' gestation with platelet counts less than 50×109/L. INTERVENTIONS Infants were randomised to undergo a platelet transfusion at platelet count thresholds of 50×109/L (higher threshold group) or 25×109/L (lower threshold group). MAIN OUTCOMES MEASURES Our prespecified long-term follow-up outcome was a composite of death or neurodevelopmental impairment (developmental delay, cerebral palsy, seizure disorder, profound hearing or vision loss) at 2 years of corrected age. RESULTS Follow-up data were available for 601 of 653 (92%) eligible participants. Of the 296 infants assigned to the higher threshold group, 147 (50%) died or survived with neurodevelopmental impairment, as compared with 120 (39%) of 305 infants assigned to the lower threshold group (OR 1.54, 95% CI 1.09 to 2.17, p=0.017). CONCLUSIONS Infants randomised to a higher platelet transfusion threshold of 50×109/L compared with 25×109/L had a higher rate of death or significant neurodevelopmental impairment at a corrected age of 2 years. This further supports evidence of harm caused by high prophylactic platelet transfusion thresholds in preterm infants. TRIAL REGISTRATION NUMBER ISRCTN87736839.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Angela D'Amore
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Cara Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Alice Newton
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Alison Deary
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Renate Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | | | - Rizwan Khan
- NICU, University Maternity Hospital Limerick, Limerick, Ireland
| | - Karen Willoughby
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wes Onland
- Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, NHS Blood and Transplant, London, UK
| | - Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Enrico Lopriore
- Neonatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Timothy Watts
- Neonatal Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Stanworth
- National Health Service Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna Curley
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
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Ribeiro HS, Assunção A, Vieira RJ, Soares P, Guimarães H, Flor-de-Lima F. Platelet transfusions in preterm infants: current concepts and controversies-a systematic review and meta-analysis. Eur J Pediatr 2023; 182:3433-3443. [PMID: 37258776 PMCID: PMC10460362 DOI: 10.1007/s00431-023-05031-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 06/02/2023]
Abstract
Platelet transfusions (PTx) are the principal approach for treating neonatal thrombocytopenia, a common hematological abnormality affecting neonates, particularly preterm infants. However, evidence about the outcomes associated with PTx and whether they provide clinical benefit or harm is lacking. The aim of this systematic review and meta-analysis is to assess the association between PTx in preterm infants and mortality, major bleeding, sepsis, and necrotizing enterocolitis (NEC) in comparison to not transfusing or using different platelet count thresholds for transfusion. A broad electronic search in three databases was performed in December 2022. We included randomized controlled trials, and cohort and case control studies of preterm infants with thrombocytopenia that (i) compared treatment with platelet transfusion vs. no platelet transfusion, (ii) assessed the platelet count threshold for PTx, or (iii) compared single to multiple PTx. We conducted a meta-analysis to assess the association between PTx and mortality, intraventricular hemorrhage (IVH), sepsis, and NEC and, in the presence of substantial heterogeneity, leave-one-out sensitivity analysis was performed. We screened 625 abstracts and 50 full texts and identified 18 reports of 13 eligible studies. The qualitative analysis of the included studies revealed controversial results as several studies showed an association between PTx in preterm infants and a higher risk of mortality, major bleeding, sepsis, and NEC, while others did not present a significant relationship. The meta-analysis results suggest a significant association between PTx and mortality (RR 2.4, 95% CI 1.8-3.4; p < 0.0001), as well as sepsis (RR 4.5, 95% CI 3.7-5.6; p < 0.0001), after a leave-one-out sensitivity analysis. There was also found a significant correlation between PTx and NEC (RR 5.2, 95% CI 3.3-8.3; p < 0.0001). As we were not able to reduce heterogeneity in the assessment of the relationship between PTx and IVH, no conclusion could be taken. Conclusion: Platelet transfusions in preterm infants are associated to a higher risk of death, sepsis, and NEC and, possibly, to a higher incidence of IVH. Further studies are needed to confirm these associations, namely between PTx and IVH, and to define the threshold from which PTx should be given with less harm effect. What is Known: • Platelet transfusions are given to preterm infants with thrombocytopenia either to treat bleeding or to prevent hemorrhage. • Lack of consensual criteria for transfusion. What is New: • A significant association between platelet transfusions and mortality, sepsis, and NEC.
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Affiliation(s)
| | - André Assunção
- Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Rafael José Vieira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine , University of Porto, Porto, Portugal
| | - Paulo Soares
- Department of Neonatology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Hercília Guimarães
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Filipa Flor-de-Lima
- Department of Neonatology, Centro Hospitalar Universitário de São João, Alameda Prof Hernâni Monteiro, 4200-319, Porto, Portugal.
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, University of Porto, Porto, Portugal.
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11
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Okbay Gunes A, Geter S, Avlanmis ME. The Usability of Platelet Mass Index Thresholds to Assess the Repeated Platelet Transfusion Requirements in Neonates. Indian J Hematol Blood Transfus 2023; 39:464-469. [PMID: 37304486 PMCID: PMC10247627 DOI: 10.1007/s12288-022-01604-3] [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: 01/17/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
To evaluate the usability of platelet mass index (PMI) thresholds to assess the repeated platelet transfusion requirements in neonates who have received transfusion within the previous six days. This is a retrospective cross-sectional study conducted with neonates who received prophylactic platelet transfusion. The PMI was calculated as platelet count (× 1000/mm3) × mean platelet volume (MPV) (fL). Platelet transfusions were divided into two groups as first (Group 1) and repeated transfusions (Group 2). The increment and percentage of increment in platelet counts, MPV and PMI after transfusion were compared between the two groups. The amounts of changes were calculated as: (Post-transfusion) - (Pre-transfusion values). The percentages of changes were calculated as: ([Post-transfusion - Pre-transfusion values]/Pre-tansfusion values) × 100. Eighty three platelet transfusions were analyzed in 28 neonates. The median gestational age and birth weight were 34.5 (26-37) weeks, and 2225 (752.5-2937.5) grams, respectively. There were 20 (24.1%) transfusions in Group 1, and 63 (75.9%) transfusions in Group 2. There were no differences in the amounts of changes in platelet counts, MPV and PMI between the groups (p > 0.05). When the percentages of changes were analyzed, it was found that the platelet counts and PMI in Group 1 increased to a greater extent compared to Group 2 (p = 0.026, p = 0.039, respectively), but no significant difference was found in MPV between the groups (p = 0.081). The lower percentage of change in PMI in Group 2 was associated with the lower percentage of change in platelet counts. Being transfused with adult platelets did not affect platelet volume of the neonates. Therefore, PMI thresholds can be used in neonates with a history of platelet transfusion.
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Affiliation(s)
- Asli Okbay Gunes
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Suleyman Geter
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
| | - Mehmet Emin Avlanmis
- Neonatal Intensive Care Unit, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
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12
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13
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Maurya P, Ture SK, Li C, Scheible KM, McGrath KE, Palis J, Morrell CN. Transfusion of Adult, but Not Neonatal, Platelets Promotes Monocyte Trafficking in Neonatal Mice. Arterioscler Thromb Vasc Biol 2023; 43:873-885. [PMID: 36951062 DOI: 10.1161/atvbaha.122.318162] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Thrombocytopenia is common in preterm neonates. Platelet transfusions are sometimes given to thrombocytopenic neonates with the hope of reducing the bleeding risk, however, there are little clinical data to support this practice, and platelet transfusions may increase the bleeding risk or lead to adverse complications. Our group previously reported that fetal platelets expressed lower levels of immune-related mRNA compared with adult platelets. In this study, we focused on the effects of adult versus neonatal platelets on monocyte immune functions that may have an impact on neonatal immune function and transfusion complications. METHODS Using RNA sequencing of postnatal day 7 and adult platelets, we determined age-dependent platelet gene expression. Platelets and naive bone marrow-isolated monocytes were cocultured and monocyte phenotypes determined by RNA sequencing and flow cytometry. An in vivo model of platelet transfusion in neonatal thrombocytopenic mice was used in which platelet-deficient TPOR (thrombopoietin receptor) mutant mice were transfused with adult or postnatal day 7 platelets and monocyte phenotypes and trafficking were determined. RESULTS Adult and neonatal platelets had differential immune molecule expression, including Selp. Monocytes incubated with adult or neonatal mouse platelets had similar inflammatory (Ly6Chi) but different trafficking phenotypes, as defined by CCR2 and CCR5 mRNA and surface expression. Blocking P-sel (P-selectin) interactions with its PSGL-1 (P-sel glycoprotein ligand-1) receptor on monocytes limited the adult platelet-induced monocyte trafficking phenotype, as well as adult platelet-induced monocyte migration in vitro. Similar results were seen in vivo, when thrombocytopenic neonatal mice were transfused with adult or postnatal day 7 platelets; adult platelets increased monocyte CCR2 and CCR5, as well as monocyte chemokine migration, whereas postnatal day 7 platelets did not. CONCLUSIONS These data provide comparative insights into adult and neonatal platelet transfusion-regulated monocyte functions. The transfusion of adult platelets to neonatal mice was associated with an acute inflammatory and trafficking monocyte phenotype that was platelet P-sel dependent and may have an impact on complications associated with neonatal platelet transfusions.
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Affiliation(s)
- Preeti Maurya
- Aab Cardiovascular Research Institute (P.M., S.K.T., C.L., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
- Department of Pediatrics (P.M., K.M.S., K.E.M., J.P.), University of Rochester School of Medicine and Dentistry, NY
| | - Sara K Ture
- Aab Cardiovascular Research Institute (P.M., S.K.T., C.L., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
| | - Chen Li
- Aab Cardiovascular Research Institute (P.M., S.K.T., C.L., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
| | - Kristin M Scheible
- Department of Pediatrics (P.M., K.M.S., K.E.M., J.P.), University of Rochester School of Medicine and Dentistry, NY
| | - Kathleen E McGrath
- Department of Pediatrics (P.M., K.M.S., K.E.M., J.P.), University of Rochester School of Medicine and Dentistry, NY
| | - James Palis
- Department of Pediatrics (P.M., K.M.S., K.E.M., J.P.), University of Rochester School of Medicine and Dentistry, NY
- Department of Pathology and Laboratory Medicine (J.P., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
| | - Craig N Morrell
- Aab Cardiovascular Research Institute (P.M., S.K.T., C.L., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
- Department of Medicine (C.N.M.), University of Rochester School of Medicine and Dentistry, NY
- Department of Microbiology and Immunology (C.N.M.), University of Rochester School of Medicine and Dentistry, NY
- Department of Pathology and Laboratory Medicine (J.P., C.N.M.), University of Rochester School of Medicine and Dentistry, NY
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14
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Zabeida A, Chartrand L, Lacroix J, Villeneuve A. Platelet transfusion practice pattern before and after implementation of a local restrictive transfusion protocol in a neonatal intensive care unit. Transfusion 2023; 63:134-142. [PMID: 36369934 DOI: 10.1111/trf.17184] [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: 07/05/2022] [Revised: 08/25/2022] [Accepted: 10/28/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Following the results of the PlaNeT-2 randomized controlled trial showing decreased morbidity and mortality in neonates transfused at a threshold of 25 versus 50 × 109 platelets/L, a protocol supporting restrictive platelet transfusions was established in 2019 at the Sainte-Justine Hospital neonatal intensive care unit (NICU). This study aimed to: (1) determine the impact of a local restrictive transfusion protocol on the number of platelet transfusions and donor exposure; (2) compare platelet-transfusion determinants and justifications before and after its implementation. STUDY DESIGN AND METHODS Prospective observational cohort chart-review study comparing all neonates consecutively admitted to the NICU during two 5-months periods: 2013 (before; N = 401) versus 2021 (after; N = 402). Possible determinants were assessed via logistic regressions and justifications via a questionnaire. RESULTS Mean (± standard deviation) gestational age and birth weight were 34.9 ± 4.2 weeks and 2.5 ± 1.0 kg, respectively. In 2021, 5.0% were platelet-transfused versus 9.2% in 2013 (p = .027). Platelet transfusions decreased from a mean of 2.6 ± 1.7 in 2013 to 1.4 ± 0.7 in 2021 (p = .045). Adherence to protocol thresholds was of 70%. After protocol implementation, no infant received ≥4 platelet transfusions nor was exposed to ≥4 donors, compared to 29.7% and 21.6%, respectively, in 2013. Platelet transfusion justifications and determinants remained similar, except for severe intraventricular hemorrhage being an additional determinant in 2021. DISCUSSION Restrictive local transfusion thresholds in a NICU decreased the proportion of platelet-transfused neonates by 46% and reduced donor exposure in transfused patients.
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Affiliation(s)
- Alexandra Zabeida
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Quebec, Canada
| | | | - Jacques Lacroix
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada
| | - Andréanne Villeneuve
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Quebec, Canada
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15
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Peng T, Shan Y, Zhang P, Cheng G. Bleeding in neonates with severe thrombocytopenia: a retrospective cohort study. BMC Pediatr 2022; 22:730. [PMID: 36550455 PMCID: PMC9773444 DOI: 10.1186/s12887-022-03802-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe neonatal thrombocytopenia is a rare disease with multiple etiologies. Severe thrombocytopenia with bleeding is life-threatening and has attracted significant attention from clinicians. However, only a few studies have focused on the association between severe thrombocytopenia and bleeding. Thus, this study aimed to describe the neonates' postnatal age at which severe thrombocytopenia was first recognized, clinical characteristics, bleeding patterns, and outcomes and to evaluate the association between minimum platelet count and bleeding. METHODS A single-center retrospective cohort study for neonates with severe thrombocytopenia (platelet count ≤ 50 × 109/L) was conducted. Neonates who were admitted to our neonatal intensive care unit between October 2016 and February 2021 and developed severe thrombocytopenia were analyzed. Data were collected retrospectively until the patients were referred to other hospitals, discharged, or deceased. RESULTS Among the 5819 neonatal inpatients, 170 with severe thrombocytopenia were included in this study. More than 30% of the patients had severe thrombocytopenia in the first 3 days of life. Among the 118 neonates with bleeding, 47 had more than one type of pathological bleeding. Neonates with very severe thrombocytopenia (point estimate: 53.7%, 95% confidence interval [CI]: 44.2%-63.1%) had a higher incidence rate of cutaneous bleeding than those with severe thrombocytopenia (point estimate: 23.4%, 95% CI: 12.3%-34.4%). The gestational age (median: 36.2 [interquartile range [IQR]: 31.4-39.0] weeks) and birth weight (median: 2310 [IQR: 1213-3210] g) of the major bleeding group were the lowest among no bleeding, minor bleeding, and major bleeding groups. Regression analysis controlled for confounders and confirmed that a lower platelet count (odds ratio [OR]: 2.504 [95% CI: 1.180-5.314], P = 0.017) was associated with a significant increase in the rate of bleeding. Very severe thrombocytopenia (point estimate: 49.1%, 95% CI: 39.6%-58.6%) had a higher rate of platelet transfusion than severe thrombocytopenia (point estimate: 5.7%, 95% CI: 0.7%-10.7%). The mortality rate was higher in neonates with bleeding than in those without bleeding (point estimates with 95% CI: 33.1% [24.4%-41.7%] vs. 7.7% [0.2%-15.2%]). CONCLUSIONS These findings describe the incidence of severe thrombocytopenia and demonstrate that a lower platelet count is associated with an increased bleeding rate in patients with severe thrombocytopenia.
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Affiliation(s)
- Ting Peng
- grid.411333.70000 0004 0407 2968Department of Neonatology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Yuanyuan Shan
- grid.411333.70000 0004 0407 2968Department of Neonatology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Peng Zhang
- grid.411333.70000 0004 0407 2968Department of Neonatology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
| | - Guoqiang Cheng
- grid.411333.70000 0004 0407 2968Department of Neonatology, National Children’s Medical Center, Children’s Hospital of Fudan University, Shanghai, China
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16
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Chen C, Wu S, Chen J, Wu J, Mei Y, Han T, Yang C, Ouyang X, Wong MCM, Feng Z. Evaluation of the Association of Platelet Count, Mean Platelet Volume, and Platelet Transfusion With Intraventricular Hemorrhage and Death Among Preterm Infants. JAMA Netw Open 2022; 5:e2237588. [PMID: 36260331 PMCID: PMC9582899 DOI: 10.1001/jamanetworkopen.2022.37588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Platelet transfusion is commonly performed in infants to correct severe thrombocytopenia or prevent bleeding. Exploring the associations of platelet transfusion, platelet count (PC), and mean platelet volume (MPV) with intraventricular hemorrhage (IVH) and in-hospital mortality in preterm infants can provide evidence for the establishment of future practices. OBJECTIVES To evaluate the associations of platelet transfusion, PC, and MPV with IVH and in-hospital mortality and to explore whether platelet transfusion-associated IVH and mortality risks vary with PC and MPV levels at the time of transfusion. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included preterm infants who were transferred to the neonatal intensive care unit on their day of birth and received ventilation during their hospital stay. The study was conducted at a neonatal intensive care unit referral center in Beijing, China, between May 2016 and October 2017. Data were retrieved and analyzed from December 2020 to January 2022. EXPOSURES Platelet transfusion, PC, and MPV. MAIN OUTCOMES AND MEASURES Any grade IVH, severe IVH (grade 3 or 4), and in-hospital mortality. RESULTS Among the 1221 preterm infants (731 [59.9%] male; median [IQR] gestational age, 31.0 [29.0-33.0] weeks), 94 (7.7%) received 166 platelet transfusions. After adjustment for potential confounders, platelet transfusion was significantly associated with mortality (hazard ratio [HR], 1.48; 95% CI, 1.13-1.93; P = .004). A decreased PC was significantly associated with any grade IVH (HR per 50 × 103/μL, 1.13; 95% CI, 1.05-1.22; P = .001), severe IVH (HR per 50 × 103/μL, 1.16; 95% CI, 1.02-1.32; P = .02), and mortality (HR per 50 × 103/μL, 1.74; 95% CI, 1.48-2.03; P < .001). A higher MPV was associated with a lower risk of mortality (HR, 0.83; 95% CI, 0.69-0.98; P = .03). The platelet transfusion-associated risks for both IVH and mortality increased when transfusion was performed in infants with a higher PC level (eg, PC of 25 × 103/μL: HR, 1.20; 95% CI, 0.89-1.62; PC of 100 × 103/μL: HR, 1.40; 95% CI, 1.08-1.82). The platelet transfusion-associated risks of IVH and mortality varied with MPV level at the time of transfusion. CONCLUSIONS AND RELEVANCE In preterm infants, platelet transfusion, PC, and MPV were associated with mortality, and PC was also associated with any grade IVH and severe IVH. The findings suggest that a lower platelet transfusion threshold is preferred; however, the risk of a decreased PC should not be ignored.
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Affiliation(s)
- Chong Chen
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
- National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China
- Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Sicheng Wu
- Dental Public Health, Faculty of Dentistry, the University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Jia Chen
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
- National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China
- Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Jinghui Wu
- Department of Blood Transfusion, Fourth Medical Center of PLA General Hospital, Beijing, China
| | - Yabo Mei
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
- National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China
- Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Tao Han
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
- National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China
- Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Changshuan Yang
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
- National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China
- Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Xilin Ouyang
- Department of Blood Transfusion, Fourth Medical Center of PLA General Hospital, Beijing, China
| | - May Chun Mei Wong
- Dental Public Health, Faculty of Dentistry, the University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Zhichun Feng
- Department of Neonatology, Faculty of Pediatrics, Seventh Medical Center of PLA General Hospital, Beijing, China
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Davenport P, Sola‐Visner M. Platelets in the neonate: Not just a small adult. Res Pract Thromb Haemost 2022; 6:e12719. [PMID: 35592812 PMCID: PMC9102610 DOI: 10.1002/rth2.12719] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/08/2022] [Accepted: 03/31/2022] [Indexed: 12/25/2022] Open
Abstract
Neonates, particularly those born preterm, have a high incidence of thrombocytopenia and bleeding, most commonly in the brain. Because of this, it has historically been accepted that neonates should be transfused at higher platelet counts than older children or adults, to decrease their bleeding risk. However, a number of observational studies and a recent large, randomized trial found a higher incidence of bleeding and mortality in neonates who received more platelet transfusions. The mechanisms underlying the deleterious effects of platelet transfusions in neonates are unknown, but it has been hypothesized that transfusing adult platelets into the very different physiological environment of a neonate may result in a “developmental mismatch” with potential negative consequences. Specifically, neonatal platelets are hyporeactive in response to multiple agonists and upon activation express less surface P‐selectin than adult platelets. However, this hyporeactivity is well balanced by factors in neonatal blood that promote clotting, such as the elevated hematocrit, elevated von Willebrand factor (VWF) levels, and a predominance of ultra‐long VWF polymers, with the net result of normal neonatal primary hemostasis. So far, most studies on the developmental differences between neonatal and adult platelets have focused on their hemostatic functions. However, it is now clear that platelets have important nonhemostatic functions, particularly in angiogenesis, immune responses, and inflammation. Whether equally important developmental differences exist with regard to those nonhemostatic platelet functions and how platelet transfusions perturb those processes in neonates remain unanswered questions.
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Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine Boston Children's Hospital Harvard Medical School Boston MA USA
| | - Martha Sola‐Visner
- Division of Newborn Medicine Boston Children's Hospital Harvard Medical School Boston MA USA
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18
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Davenport P, Fan HH, Nolton E, Feldman HA, Lorenz V, Canas J, Acosta-Zaldívar M, Yakah W, Arthur C, Martin C, Stowell S, Koehler J, Mager D, Sola-Visner M. Platelet transfusions in a murine model of neonatal polymicrobial sepsis: Divergent effects on inflammation and mortality. Transfusion 2022; 62:1177-1187. [PMID: 35522536 DOI: 10.1111/trf.16895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Platelet transfusions (PTxs) are often given to septic preterm neonates at high platelet count thresholds in an attempt to reduce bleeding risk. However, the largest randomized controlled trial (RCT) of neonatal transfusion thresholds found higher mortality and/or major bleeding in infants transfused at higher thresholds. Using a murine model, we investigated the effects of adult PTx on neonatal sepsis-induced mortality, systemic inflammation, and platelet consumption. STUDY DESIGN AND METHODS Polymicrobial sepsis was induced via intraperitoneal injection of cecal slurry preparations (CS1, 2, 3) into P10 pups. Two hours after infection, pups were transfused with washed adult Green Flourescent Protein (GFP+) platelets or control. Weights, platelet counts, and GFP% were measured before 4 and 24 h post-infection. At 24 h, blood was collected for quantification of plasma cytokines. RESULTS The CS batches varied in 24 h mortality (11%, 73%, and 30% in CS1, 2, and 3, respectively), due to differences in bacterial composition. PTx had differential effects on sepsis-induced mortality and systemic inflammatory cytokines, increasing both in mice infected with CS1 (low mortality) and decreasing both in mice infected with CS2 and 3. In a mathematical model of platelet kinetics, the consumption of transfused adult platelets was higher than that of endogenous neonatal platelets, regardless of CS batch. DISCUSSION Our findings support the hypothesis that transfused adult platelets are consumed faster than endogenous neonatal platelets in sepsis and demonstrate that PTx can enhance or attenuate neonatal inflammation and mortality in a model of murine polymicrobial sepsis, depending on the composition of the inoculum and/or the severity of sepsis.
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Affiliation(s)
- Patricia Davenport
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Hsuan-Hao Fan
- Department of Pharmaceutical Sciences, University of Buffalo, State University of New York, Buffalo, New York, USA
| | - Emily Nolton
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry A Feldman
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Viola Lorenz
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge Canas
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - William Yakah
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neonatology, Beth Israel Medical Center, Boston, Massachusetts, USA
| | - Connie Arthur
- Division of Transfusion Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Camilia Martin
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neonatology, Beth Israel Medical Center, Boston, Massachusetts, USA
| | - Sean Stowell
- Division of Transfusion Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Koehler
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.,Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald Mager
- Department of Pharmaceutical Sciences, University of Buffalo, State University of New York, Buffalo, New York, USA
| | - Martha Sola-Visner
- Division of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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19
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Abiramalatha T, Vadakkencherry Ramaswamy V, Thanigainathan S. Platelet transfusions in neonates-Unresolved aspects and future directions. Pediatr Blood Cancer 2022; 69:e29608. [PMID: 35187787 DOI: 10.1002/pbc.29608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India.,Department of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | | | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Delaney M, Karam O, Lieberman L, Steffen K, Muszynski JA, Goel R, Bateman ST, Parker RI, Nellis ME, Remy KE. What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e1-e13. [PMID: 34989701 PMCID: PMC8769352 DOI: 10.1097/pcc.0000000000002854] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection? CONCLUSIONS The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.
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Affiliation(s)
- Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children’s National Hospital; Department of Pathology & Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Katherine Steffen
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stanford University, Palo Alto, CA
| | - Jennifer A. Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus, OH
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Scot T. Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Robert I. Parker
- Emeritus, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Marianne E. Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth E. Remy
- Department of Pediatrics, Division of Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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Moore CM, Curley AE. Neonatal Platelet Transfusions: Starting Again. Transfus Med Rev 2021; 35:29-35. [PMID: 34312045 DOI: 10.1016/j.tmrv.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
Preterm neonates with severe thrombocytopenia are frequently prescribed prophylactic platelet transfusions despite no evidence of benefit. Neonatal platelet transfusion practice varies, both nationally and internationally. Volumes and rates of transfusion in neonatology are based on historic precedent and lack an evidence base. The etiology of harm from platelet transfusions is poorly understood. Neonates are expected to be the longest surviving recipients of blood produce transfusions, and so avoiding transfusion associated harm is critical in this cohort. This article reviews the evidence for and against platelet transfusion in the neonate and identifies areas of future potential neonatal platelet transfusion research.
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Affiliation(s)
- Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin 2, D02YH21, Ireland.
| | - Anna E Curley
- Department of Neonatology, National Maternity Hospital, Dublin 2, D02YH21, Ireland
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Maheshwari A. Role of platelets in neonatal necrotizing enterocolitis. Pediatr Res 2021; 89:1087-1093. [PMID: 32601461 PMCID: PMC7770063 DOI: 10.1038/s41390-020-1038-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/10/2020] [Accepted: 06/17/2020] [Indexed: 12/23/2022]
Abstract
Necrotizing enterocolitis (NEC) is an inflammatory bowel necrosis of premature infants and is a leading cause of morbidity and mortality in infants born between 23 and 28 weeks of gestation. Fifty to 95% of all infants with NEC develop thrombocytopenia (platelet counts <150 × 109/L) within 24-72 h of receiving this diagnosis. In many patients, thrombocytopenia is severe and is treated with one or more platelet transfusions. However, the underlying mechanism(s) and biological implications of NEC-related thrombocytopenia remain unclear. This review presents current evidence from human and animal studies on the clinical features and mechanisms of platelet depletion in NEC. Anecdotal clinical experience is combined with evidence from laboratory studies and from an extensive literature search in databases PubMed, EMBASE, and Scopus and the electronic archives of abstracts presented at the annual meetings of the Pediatric Academic Societies. To avoid bias in identification of existing studies, key words were short-listed prior to the actual search both from anecdotal experience and from PubMed's Medical Subject Heading (MeSH) thesaurus. IMPACT: Fifty to 95% of infants with necrotizing enterocolitis (NEC) develop idiopathic thrombocytopenia (platelet counts <150 × 109/L) within 24-72 h of disease onset. Early clinical trials suggest that moderate thrombocytopenia may be protective in human NEC, although further work is needed to fully understand this relationship. We have developed a neonatal murine model of NEC-related thrombocytopenia, where enteral administration of an immunological stimulant, trinitrobenzene sulfonate, on postnatal day 10 induces an acute necrotizing ileocolitis resembling human NEC. In this murine model, thrombocytopenia is seen at 15-18 h due to platelet consumption and mild-moderate thrombocytopenia is protective.
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Affiliation(s)
- Akhil Maheshwari
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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23
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Implementation of a neonatal platelet transfusion guideline to reduce non-indicated transfusions using a quality improvement framework. J Perinatol 2021; 41:1487-1494. [PMID: 33758388 PMCID: PMC7985577 DOI: 10.1038/s41372-021-01033-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/11/2021] [Accepted: 02/25/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Variation exists in neonatal platelet transfusion practices. Recent studies found potential harm in liberal platelet transfusion practices, supporting the use of lower transfusion thresholds. Our aim was to reduce non-indicated platelet transfusions through implementation of a restrictive platelet transfusion guideline. STUDY DESIGN Platelet transfusions from January 2017 to December 2019 were classified as indicated or non-indicated using the new guideline. Interventions included guideline implementation and staff education. Outcomes were evaluated using statistical process control charts. Major bleeding was the balancing measure. RESULT During study, 438 platelet transfusions were administered to 105 neonates. The mean number of non-indicated platelet transfusions/month decreased from 7.3 to 1.6. The rate of non-indicated platelet transfusions per 100 patient admissions decreased from 12.5 to 2.9. Rates of major bleeding remained stable. CONCLUSIONS Implementation of a restrictive neonatal platelet transfusion guideline significantly reduced potentially harmful platelet transfusions in our NICU without a change in major bleeding.
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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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25
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Targeted inhibition of thrombin attenuates murine neonatal necrotizing enterocolitis. Proc Natl Acad Sci U S A 2020; 117:10958-10969. [PMID: 32366656 DOI: 10.1073/pnas.1912357117] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is an inflammatory bowel necrosis of premature infants and an orphan disease with no specific treatment. Most patients with confirmed NEC develop moderate-severe thrombocytopenia requiring one or more platelet transfusions. Here we used our neonatal murine model of NEC-related thrombocytopenia to investigate mechanisms of platelet depletion associated with this disease [K. Namachivayam, K. MohanKumar, L. Garg, B. A. Torres, A. Maheshwari, Pediatr. Res. 81, 817-824 (2017)]. In this model, enteral administration of immunogen trinitrobenzene sulfonate (TNBS) in 10-d-old mouse pups produces an acute necrotizing ileocolitis resembling human NEC within 24 h, and these mice developed thrombocytopenia at 12 to 15 h. We hypothesized that platelet activation and depletion occur during intestinal injury following exposure to bacterial products translocated across the damaged mucosa. Surprisingly, platelet activation began in our model 3 h after TNBS administration, antedating mucosal injury or endotoxinemia. Platelet activation was triggered by thrombin, which, in turn, was activated by tissue factor released from intestinal macrophages. Compared to adults, neonatal platelets showed enhanced sensitivity to thrombin due to higher expression of several downstream signaling mediators and the deficiency of endogenous thrombin antagonists. The expression of tissue factor in intestinal macrophages was also unique to the neonate. Targeted inhibition of thrombin by a nanomedicine-based approach was protective without increasing interstitial hemorrhages in the inflamed bowel or other organs. In support of these data, we detected increased circulating tissue factor and thrombin-antithrombin complexes in patients with NEC. Our findings show that platelet activation is an important pathophysiological event and a potential therapeutic target in NEC.
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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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Abstract
Thrombocytopenia is common in preterm neonates. Thresholds for prophylactic platelet transfusion vary widely due to lack of evidence. The results of the PlaNet-2/MATISSE Study identified harm in the form of mortality and major bleed in babies prophylactically transfused below a platelet count of 50 × 109/L compared to 25 × 109/L. Neonatal platelet transfusions are administered at volumes based on historical practice which greatly exceed those routinely used in adults. Rate of transfusion is also based around practice in trauma and does not take into account the physiology of the preterm infant. There are multiple ways in which platelets may be mediating harm and this review discusses these potential mechanisms including immunological, inflammatory and blood group incompatibility. Much of the difficulty in assessing harm relates to problems in classification of transfusion-associated adverse events in babies. Thrombocytopenia and timing, efficacy and adverse effects of platelet transfusion are poorly understood. Further research is essential.
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Affiliation(s)
| | - Anna Curley
- National Maternity Hospital, Holles Street, Dublin 2, Ireland.
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28
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Esiaba I, Mousselli I, M. Faison G, M. Angeles D, S. Boskovic D. Platelets in the Newborn. NEONATAL MEDICINE 2019. [DOI: 10.5772/intechopen.86715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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29
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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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31
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Tiong XT, Nursara Shahirah A, Pun VC, Wong KY, Fong AYY, Sy RG, Castillo-Carandang NT, Nang EEK, Woodward M, van Dam RM, Tai ES, Venkataraman K. The association of the dietary approach to stop hypertension (DASH) diet with blood pressure, glucose and lipid profiles in Malaysian and Philippines populations. Nutr Metab Cardiovasc Dis 2018; 28:856-863. [PMID: 29853430 DOI: 10.1016/j.numecd.2018.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/30/2018] [Accepted: 04/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Despite a growing body of evidence from Western populations on the health benefits of Dietary Approaches to Stop Hypertension (DASH) diets, their applicability in South East Asian settings is not clear. We examined cross-sectional associations between DASH diet and cardio-metabolic risk factors among 1837 Malaysian and 2898 Philippines participants in a multi-national cohort. METHODS AND RESULTS Blood pressures, fasting lipid profile and fasting glucose were measured, and DASH score was computed based on a 22-item food frequency questionnaire. Older individuals, women, those not consuming alcohol and those undertaking regular physical activity were more likely to have higher DASH scores. In the Malaysian cohort, while total DASH score was not significantly associated with cardio-metabolic risk factors after adjusting for confounders, significant associations were observed for intake of green vegetable [0.011, standard error (SE): 0.004], and red and processed meat (-0.009, SE: 0.004) with total cholesterol. In the Philippines cohort, a 5-unit increase in total DASH score was significantly and inversely associated with systolic blood pressure (-1.41, SE: 0.40), diastolic blood pressure (-1.09, SE: 0.28), total cholesterol (-0.015, SE: 0.005), low-density lipoprotein cholesterol (-0.025, SE: 0.008), and triglyceride (-0.034, SE: 0.012) after adjusting for socio-demographic and lifestyle groups. Intake of milk and dairy products, red and processed meat, and sugared drinks were found to significantly associated with most risk factors. CONCLUSIONS Differential associations of DASH diet and dietary components with cardio-metabolic risk factors by country suggest the need for country-specific tailoring of dietary interventions to improve cardio-metabolic risk profiles.
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Affiliation(s)
- X T Tiong
- Clinical Research Centre, Sarawak General Hospital, Kuching, Malaysia
| | | | - V C Pun
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - K Y Wong
- Clinical Research Centre, Sarawak General Hospital, Kuching, Malaysia
| | - A Y Y Fong
- Clinical Research Centre, Sarawak General Hospital, Kuching, Malaysia; Department of Cardiology, Sarawak General Hospital Heart Centre, Kota Samarahan, Malaysia
| | - R G Sy
- Department of Medicine, University of the Philippines, Philippine General Hospital, Manila, Philippines; LIFECourse study in Cardiovascular Disease Epidemiology (LIFECARE), Philippines Study Group, Lipid Research Unit, UP-PGH, UP, Manila, Philippines
| | - N T Castillo-Carandang
- LIFECourse study in Cardiovascular Disease Epidemiology (LIFECARE), Philippines Study Group, Lipid Research Unit, UP-PGH, UP, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine; and Institute of Clinical Epidemiology, National Institutes of Health, University of Philippines, Manila, Philippines
| | - E E K Nang
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - M Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia; The George Institute for Global Health, University of Oxford, UK; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - R M van Dam
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - E S Tai
- Department of Medicine, National University of Singapore and National University Health System, Singapore
| | - K Venkataraman
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
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Abstract
Transfusions of red blood cells (RBCs), platelets, and plasma are critical therapies for infants and neonates (particularly preterm neonates) in the neonatal intensive care unit, who are the most frequently transfused subpopulation across all ages. Although traditionally a significant gap has existed between the blood utilization and the evidence base essential to adequately guide transfusion practices in infants and neonates, pediatric transfusion medicine is evolving from infancy and gradually coming of age. It is entering an exciting era with recognition as an independent discipline, a new and evolving high-quality evidence base for transfusion practices, novel technologies and therapeutics, and national/international collaborative research, educational, and clinical efforts. Triggers and thresholds for red cell transfusion are accumulating evidence with current phase III clinical trials. Ongoing trials and studies of platelet and plasma transfusions in neonates are anticipated to provide high-quality evidence in years to come. This article aims to summarize the most current evidence-based practices regarding blood component therapy in neonates. Data on the use of specific components (RBCs, plasma, and platelets) are provided. We attempt to define thresholds for anemia, thrombocytopenia, and abnormal coagulation profile in neonates to highlight the difficulties in having a specific cutoff value in neonates and preterm infants. Indications for transfusion of specific products, transfusion thresholds, and current practices and guidelines are provided, and possible adverse outcomes and complications are discussed. Finally, the critical research knowledge gaps in these practices as well as ongoing and future research areas are discussed. In an era of personalized medicine, neonatal transfusion decisions guided by a strong evidence base must be the overarching goal, and this underlies all of the strategic initiatives in pediatric and neonatal transfusion research highlighted in this article.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology and Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Cassandra D Josephson
- Departments of Pathology and Pediatrics, Center for Transfusion and Cellular Therapies, Emory University School of Medicine and AFLAC Cancer Center and Blood Disorders Service, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Wu L, Pang S, Yao Q, Jian C, Lin P, Feng F, Li H, Li Y. Population-based study of effectiveness of neoadjuvant radiotherapy on survival in US rectal cancer patients according to age. Sci Rep 2017; 7:3471. [PMID: 28615639 PMCID: PMC5471198 DOI: 10.1038/s41598-017-02992-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 04/21/2017] [Indexed: 12/18/2022] Open
Abstract
Recent cancer researches pay more attention to younger patients due to the variable treatment response among different age groups. Here we investigated the effectiveness of neoadjuvant radiation on the survival of younger and older patients in stage II/III rectal cancer. Data was obtained from Surveillance, Epidemiology, and End Results (SEER) database (n = 12801). Propensity score matching was used to balance baseline covariates according to the status of neoadjuvant radiation. Our results showed that neoadjuvant radiation had better survival benefit (Log-rank P = 3.25e-06) and improved cancer-specific 3-year (87.6%; 95% CI: 86.4–88.7% vs. 84.1%; 95% CI: 82.8–85.3%) and 5-year survival rates (78.1%; 95% CI: 76.2–80.1% vs. 77%; 95% CI: 75.3–78.8%). In older groups (>50), neoadjuvant radiation was associated with survival benefits in stage II (HR: 0.741; 95% CI: 0.599–0.916; P = 5.80e-3) and stage III (HR: 0.656; 95% CI 0.564–0.764; P = 5.26e-08). Interestingly, neoadjuvant radiation did not increase survival rate in younger patients (< = 50) both in stage II (HR: 2.014; 95% CI: 0.9032–4.490; P = 0.087) and stage III (HR: 1.168; 95% CI: 0.829–1.646; P = 0.372). Additionally, neoadjuvant radiation significantly decreased the cancer-specific mortality in older patients, but increased mortality in younger patients. Our results provided new insights on the neoadjuvant radiation in rectal cancer, especially for the younger patients.
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Affiliation(s)
- Leilei Wu
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Shichao Pang
- Department of Statistics, School of Mathematical Sciences, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Qianlan Yao
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Chen Jian
- Department of General Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Songjiang District, 201600, shanghai, China
| | - Ping Lin
- CAS Key Laboratory for Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Fangyoumin Feng
- CAS Key Laboratory for Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.,School of Life Science and Technology, ShanghaiTech University, Shanghai, 201210, China
| | - Hong Li
- CAS Key Laboratory for Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China.
| | - Yixue Li
- School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, 200240, China. .,CAS Key Laboratory for Computational Biology, CAS-MPG Partner Institute for Computational Biology, Shanghai Institute for Biological Sciences, Chinese Academy of Sciences, Shanghai, 200031, China. .,Collaborative Innovation Center of Genetics and Development, Fudan University, Shanghai, 200433, China.
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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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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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Girelli G, Antoncecchi S, Casadei AM, Del Vecchio A, Isernia P, Motta M, Regoli D, Romagnoli C, Tripodi G, Velati C. Recommendations for transfusion therapy in neonatology. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:484-97. [PMID: 26445308 PMCID: PMC4607607 DOI: 10.2450/2015.0113-15] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Gabriella Girelli
- Immunohaematology and Transfusion Medicine Unit, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | | | - Anna Maria Casadei
- University Department of Paediatrics and Childhood Neuropsychiatry, Sapienza University of Rome, Rome, Italy
| | | | - Paola Isernia
- Department of Transfusion Medicine and Haematology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Mario Motta
- Neonatology and Neonatal Intensive Care, Spedali Civili, Brescia, Italy
| | - Daniela Regoli
- Neonatology, Pathology and Neonatal Intensive Care Unit, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | | | - Gino Tripodi
- Immunohaematology and Transfusion Centre, "G. Gaslini" Institute, Genoa, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, as Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) and Italian Society of Neonatology (SIN) working group
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Josephson CD, Mondoro TH, Ambruso DR, Sanchez R, Sloan SR, Luban NL, Widness JA. One size will never fit all: the future of research in pediatric transfusion medicine. Pediatr Res 2014; 76:425-31. [PMID: 25119336 PMCID: PMC4408868 DOI: 10.1038/pr.2014.120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 05/21/2014] [Indexed: 01/19/2023]
Abstract
There is concern at the National Heart, Lung, and Blood Institute (NHLBI) and among transfusion medicine specialists regarding the small number of investigators and studies in the field of pediatric transfusion medicine (PTM). Accordingly, the objective of this article is to provide a snapshot of the clinical and translational PTM research considered to be of high priority by pediatricians, neonatologists, and transfusion medicine specialists. Included is a targeted review of three research areas of importance: (i) transfusion strategies, (ii) short- and long-term clinical consequences, and (iii) transfusion-transmitted infectious diseases. The recommendations by PTM and transfusion medicine specialists represent opportunities and innovative strategies to execute translational research, observational studies, and clinical trials of high relevance to PTM. With the explosion of new biomedical knowledge and increasingly sophisticated methodologies over the past decade, this is an exciting time to consider transfusion medicine as a paradigm for addressing questions related to fields such as cell biology, immunology, neurodevelopment, outcomes research, and many others. Increased awareness of PTM as an important, fertile field and the promotion of accompanying opportunities will help establish PTM as a viable career option and advance basic and clinical investigation to improve the health and wellbeing of children.
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Affiliation(s)
- Cassandra D. Josephson
- Department of Pathology and Laboratory Medicine and Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, US
| | - Traci Heath Mondoro
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, US
| | | | - Rosa Sanchez
- Blood Systems Research Institute, San Francisco, CA, US
| | - Steven R. Sloan
- Joint Program in Transfusion Medicine, Children’s Hospital, Boston, MA, US
| | | | - John A. Widness
- Department of Pediatrics, University of Iowa, Iowa City, IA, US
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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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Abstract
Thrombocytopenia is a very frequent problem among sick neonates, affecting up to 35% of all infants admitted to the neonatal intensive care unit (NICU), and serves as an important indicator of multiple clinical conditions. The cause of the thrombocytopenia is unclear in up to 60% of affected neonates. A clinical classification of thrombocytopenia is based on the time of presentation, early (≤72 hours of life) vs. late (>72 hours of life). Early thrombocytopenia is commonly associated with feto-maternal conditions, is most commonly caused by disorders associated with placental insufficiency, and is generally mild to moderate and resolves spontaneously within 7-10 days without any intervention. In contrast, neonates who develop late-onset thrombocytopenia frequently have bacterial sepsis or necrotizing enterocolitis. It is often severe (platelets <50,000/μL), prolonged and frequently requires multiple platelet transfusions. Platelet transfusions represent the only specific therapy currently available for most thrombocytopenic neonates, even though much evidence suggests that platelet transfusions are not benign. Many of the prophylactic platelet transfusions currently given to NICU patients are unnecessary, convey no benefits, and carry known and unknown risks. For this reason, pharmacological alternatives have been investigated as potential therapies for thrombocytopenia, but they still have limited use treating the common varieties of neonatal thrombocytopenia.
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Affiliation(s)
- Antonio Del Vecchio
- Department of Maternal and Child Health, Division of Neonatology, Neonatal Intensive Care Unit, Di Venere Hospital, Bari, Italy.
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40
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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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Bıçakçı Z, Olcay L. Citrate metabolism and its complications in non-massive blood transfusions: association with decompensated metabolic alkalosis+respiratory acidosis and serum electrolyte levels. Transfus Apher Sci 2014; 50:418-26. [PMID: 24661844 DOI: 10.1016/j.transci.2014.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 02/11/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Metabolic alkalosis, which is a non-massive blood transfusion complication, is not reported in the literature although metabolic alkalosis dependent on citrate metabolism is reported to be a massive blood transfusion complication. The aim of this study was to investigate the effect of elevated carbon dioxide production due to citrate metabolism and serum electrolyte imbalance in patients who received frequent non-massive blood transfusions. MATERIALS AND METHODS Fifteen inpatients who were diagnosed with different conditions and who received frequent blood transfusions (10-30 ml/kg/day) were prospectively evaluated. Patients who had initial metabolic alkalosis (bicarbonate>26 mmol/l), who needed at least one intensive blood transfusion in one-to-three days for a period of at least 15 days, and whose total transfusion amount did not fit the massive blood transfusion definition (<80 ml/kg) were included in the study. RESULTS The estimated mean total citrate administered via blood and blood products was calculated as 43.2 ± 34.19 mg/kg/day (a total of 647.70 mg/kg in 15 days). Decompensated metabolic alkalosis+respiratory acidosis developed as a result of citrate metabolism. There was a positive correlation between cumulative amount of citrate and the use of fresh frozen plasma, venous blood pH, ionized calcium, serum-blood gas sodium and mortality, whereas there was a negative correlation between cumulative amount of citrate and serum calcium levels, serum phosphorus levels and amount of urine chloride. CONCLUSION In non-massive, but frequent blood transfusions, elevated carbon dioxide production due to citrate metabolism causes intracellular acidosis. As a result of intracellular acidosis compensation, decompensated metabolic alkalosis+respiratory acidosis and electrolyte imbalance may develop. This situation may contribute to the increase in mortality. In conclusion, it should be noted that non-massive, but frequent blood transfusions may result in certain complications.
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Affiliation(s)
- Zafer Bıçakçı
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Unit of Pediatric Hematology, Demetevler, Ankara, Turkey.
| | - Lale Olcay
- Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Unit of Pediatric Hematology, Demetevler, Ankara, Turkey.
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43
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Kahvecioglu D, Erdeve O, Alan S, Cakir U, Yildiz D, Atasay B, Arsan S. The impact of evaluating platelet transfusion need by platelet mass index on reducing the unnecessary transfusions in newborns. J Matern Fetal Neonatal Med 2014; 27:1787-9. [DOI: 10.3109/14767058.2013.879708] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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44
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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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45
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Venkatesh V, Curley AE, Clarke P, Watts T, Stanworth SJ. Do we know when to treat neonatal thrombocytopaenia? Arch Dis Child Fetal Neonatal Ed 2013; 98:F380-2. [PMID: 23531628 DOI: 10.1136/archdischild-2012-302535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Vidheya Venkatesh
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, UK
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46
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Christensen RD, Ilstrup S. Recent advances toward defining the benefits and risks of erythrocyte transfusions in neonates. Arch Dis Child Fetal Neonatal Ed 2013; 98:F365-72. [PMID: 22751184 DOI: 10.1136/archdischild-2011-301265] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Like many treatments available to small or ill neonates, erythrocyte transfusions carry both benefits and risks. This review examines recent publications aimed at better defining those benefits and those risks, as means of advancing evidence-based neonatal intensive care unit transfusion practices. Since decisions regarding whether to not to order an erythrocyte transfusion are based, in part, on the neonate's blood haemoglobin concentration, the authors also review recent studies aimed at preventing the haemoglobin from falling to a point where a transfusion is considered.
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47
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Ulusoy E, Tüfekçi Ö, Duman N, Kumral A, İrken G, Ören H. Thrombocytopenia in neonates: causes and outcomes. Ann Hematol 2013; 92:961-7. [DOI: 10.1007/s00277-013-1726-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 03/06/2013] [Indexed: 10/27/2022]
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48
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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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49
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Honohan Á, van't Ende E, Hulzebos C, Lopriore E, van't Verlaat E, Govaert P, Brand A, van der Bom J. Posttransfusion platelet increments after different platelet products in neonates: a retrospective cohort study. Transfusion 2013; 53:3100-9. [DOI: 10.1111/trf.12127] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 12/20/2012] [Accepted: 12/20/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Áine Honohan
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Ella van't Ende
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Christian Hulzebos
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Enrico Lopriore
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Ellen van't Verlaat
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Paul Govaert
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Anneke Brand
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
| | - Johanna van der Bom
- Sanquin-LUMC Jon J. van Rood Center for Clinical Transfusion Research; Leiden the Netherlands
- Sanquin Blood Supply Foundation; Amsterdam the Netherlands
- Department of Pediatrics; Division of Neonatology; Beatrix Children's Hospital; University Medical Center; Groningen the Netherlands
- Department of Pediatrics; Division of Neonatology; Department of Clinical Epidemiology; Leiden University Medical Center; Leiden the Netherlands
- Department of Pediatrics; Division of Neonatology; Sophia Children's Hospital; Erasmus Medical Center; Rotterdam the Netherlands
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50
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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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