Fresh frozen plasma and recombinant factor VIIa use in neonates

Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed?

The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.

Fresh frozen plasma and cryoprecipitate: Can we safely reduce their use in the NICU?

OBJECTIVE

To study patterns of use of Fresh Frozen Plasma (FFP) and Cryoprecipitate (CRYO) in a level 4 NICU and assess what proportions were not supported by literature.

STUDY DESIGN

single centered retrospective observational. Charts of neonates admitted between 1/1/2010 to 12/31/2017 to CT Children's level 4 NICU were reviewed. Transfusions were assigned as "supported" or "non-supported" based on available evidence. Groups were compared using T-tests and chi-squared analyses.

RESULTS

of 4110 total admissions, 197 (4.8%) received a total of 461 transfusions (374 FFP, 87 CRYO). Only 59% of FFP and 60% CRYO were supported by literature. Within the "non-supported" group the largest category was neonates transfused prophylactically.

CONCLUSION

A large proportion of transfusions administered to neonates was not evidence-based, suggesting there are opportunities for improvement in use of these products.

Hemostatic Challenges in Neonates

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.

Changes in the Use of Fresh-Frozen Plasma Transfusions in Preterm Neonates: A Single Center Experience

The aim of this study was to evaluate changes in the use of fresh-frozen plasma (FFP) transfusions and the use of clotting tests in preterm neonates in our center over the past two decades. In this retrospective cohort analysis, we included all consecutive neonates with a gestational age at birth between 24 + 0 and 31 + 6 weeks admitted to our neonatal intensive care unit (NICU) between 2004 and 2019. We divided all included neonates into three consecutive time epochs according to date of birth: January 2004 to April 2009, May 2009 to August 2014 and September 2014 to December 2019. The main outcomes were the use of FFP transfusion, coagulation testing and the indications for FFP transfusion. The percentage of preterm neonates receiving FFP transfusion decreased from 5.7% (47/824) to 3.7% (30/901) to 2.0% (17/852) from the first epoch to the last epoch (p < 0.001). Additionally, the rate of neonates undergoing coagulation testing decreased from 24.3% (200/824) to 14.5% (131/901) to 8% (68/852) over the epochs (p < 0.001). Most FFP transfusions were prescribed prophylactically based on prolongation of activated partial thromboplastin time (aPTT) or prothrombin time (PT) (56%). In conclusion, both the use of FFP transfusions and the use of coagulation tests decreased significantly over the years. The majority of the FFP transfusions were administrated prophylactically for abnormal coagulation tests.

Neonatal Plasma Transfusion: An Evidence-Based Review

Several clinical scenarios for plasma transfusion are repeatedly identified in audits, including treatment of bleeding in association with laboratory evidence of coagulopathy, correction of disseminated intravascular coagulation, prevention of intraventricular hemorrhage, management of critically ill neonates (eg, during sepsis or as a volume expander), or correction of markers of prolonged coagulation in the absence of bleeding. The findings of at least one national audit of transfusion practice indicated that almost half of plasma transfusions are given to neonates with abnormal coagulation values with no evidence of active bleeding, despite the limited evidence base to support the effectiveness of this practice. Plasma transfusions to neonates should be considered in the clinical context of bleeding (eg, vitamin K dependent), disseminated intravascular coagulation, and very rare inherited deficiencies of coagulation factors. There seems to be no role for prophylactic plasma to prevent intraventricular hemorrhage or for use as a volume expander.

Optimizing operational efficiencies in early phase trials: The Pediatric Trials Network experience

Performing drug trials in pediatrics is challenging. In support of the Best Pharmaceuticals for Children Act, the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the formation of the Pediatric Trials Network (PTN) in 2010. Since its inception, the PTN has developed strategies to increase both efficiency and safety of pediatric drug trials. Through use of innovative techniques such as sparse and scavenged blood sampling as well as opportunistic study design, participation in trials has grown. The PTN has also strived to improve consistency of adverse event reporting in neonatal drug trials through the development of a standardized adverse event table. We review how the PTN is optimizing operational efficiencies in pediatric drug trials to increase the safety of drugs in children.

Fresh Frozen Plasma Administration in the Neonatal Intensive Care Unit: Evidence-Based Guidelines

Neonates receiving fresh frozen plasma (FFP) should do so according to evidence-based guidelines so as to reduce inappropriate use of this life-saving and costly blood product and to minimize associated adverse effects. The consensus-based uses of FFP in neonatology involve neonates with active bleeding and associated coagulopathy. However, because of limited and poor-quality evidence, considerable FFP utilization occurs outside these recommendations. In this review, we describe what we conclude are currently the best practices for the use of FFP in neonates, including interpreting neonatal coagulation tests and strategies for reducing unnecessary FFP transfusions.

Fresh Frozen Plasma Use in a Neonatal Unit in South Africa

BACKGROUND

Despite limited evidence, fresh frozen plasma (FFP) transfusions are a relatively common neonatal procedure.

OBJECTIVES

Quantify FFP usage in our unit; determine indications for transfusions and compliance with published guidelines.

METHODS

Data were retrospectively collected on infants who received FFP from January 2009 to December 2013.

RESULTS

Admissions totalled 10 912 infants during the study period. In total, 113 case notes were reviewed and 142 FFP transfusions were administered. Infants receiving FFP had a high mortality rate (54.87%) and an increased odds ratio for mortality 17.9 (95% confidence interval 12.0-26.6). In total, 75% FFP transfusions were compliant with guidelines. The difference between pre- and post-transfusion coagulation profile in 36.3% of infants was not statistically significant.

CONCLUSIONS

FFP was often used in accordance with published guidelines in our neonatal unit. However, the appropriate use and effectiveness of FFP in improving neonatal outcomes undermines the rationale for FFP usage in current guidelines.

Temporal changes in blood product usage in preterm neonates born at less than 30 weeks' gestation in Canada

BACKGROUND

Knowledge of neonatal transfusion practices remains limited to local cohorts or survey-based studies. This study evaluated the pattern and temporal changes in the types and frequency of blood product use among preterm neonates born at less than 30 weeks' gestation in Canada.

STUDY DESIGN AND METHODS

A retrospective cohort study of preterm neonates born at less than 30 weeks' gestation and admitted to participating neonatal intensive care units in the Canadian Neonatal Network from 2004 to 2012 was conducted to evaluate blood product usage. The temporal change in red blood cell (RBC) use was evaluated by dividing the study period into three epochs: 2004 to 2006, 2007 to 2009, and 2010 to 2012.

RESULTS

Of 14,868 eligible neonates admitted to participating units in Canada during the overall study period, 8252 (56%) received RBCs, 2151 (15%) platelets, 1556 (11%) fresh-frozen plasma, 915 (6%) albumin, and 302 (2%) cryoprecipitate. Temporal evaluation over three epochs revealed a trend toward fewer RBC transfusions among neonates born at 26 to 29 weeks' gestation (p = <0.01-0.04) but use remained unchanged or increased for neonates born at 23 to 25 weeks' gestation (p = 0.02-0.54).

CONCLUSION

Blood product use remains at a very high frequency in preterm neonates born at less than 30 weeks' gestation. Evolutionary practice changes and relative high tolerance for anemia may be associated with a reduction in RBC usage in recent years in neonates born at at least 26 weeks' gestation. This contrasts with the ongoing higher usage of blood products observed at extremely low gestational ages.

Fresh frozen plasma use in the NICU: a prospective, observational, multicentred study

OBJECTIVES

To examine the use of fresh frozen plasma (FFP) in Italian neonatal intensive care units (NICUs); specifically to quantify compliance with guideline recommendations and to evaluate the relationship between coagulation tests and subsequent bleeding episodes.

DESIGN

Prospective, observational study.

SETTING

Seventeen Italian NICUs.

PATIENTS AND METHODS

Over a period of 12 months, for all neonates that received FFP we recorded specific characteristics, pretransfusion and post-transfusion laboratory test of haemostasis, and details of all haemorrhagic events.

RESULTS

Among 3506 NICU admissions, 290 (8.2%) received one or more FFP transfusions during their hospital stay. Of these, 37% received FFP because of active bleeding and 63% received FFP prophylactically with the intention of preventing haemorrhage. A total of 609 FFP transfusions were administered (mean 2.1/transfused patient-range 1-25). Using previously agreed upon criteria, we judged that 60% of the 609 FFP transfusions were not compliant with guideline recommendations. By logistic regression, abnormalities in the prothrombin time, activated partial thromboplastin time, fibrinogen and platelet count were not independently associated with bleeding episodes.

CONCLUSIONS

FFP transfusion is a relatively frequent intervention in the NICU. In the present analysis, we found a remarkably high proportion of FFP transfusions given to non-bleeding neonates for indications not compliant with guideline recommendations. Platelet counts and coagulation studies were poor predictors of clinical bleeding.

Fresh frozen plasma: the most commonly prescribed hemostatic agent

Although fresh frozen plasma (FFP) is one of the most commonly prescribed therapies in clinical practice throughout the world today, there is little medical evidence available supporting its use. Recent guidelines have called for limiting FFP transfusions. Despite this, FFP use does not seem to be decreasing. The reasons for this are likely to be multifactorial, and may be based on ideas regarding medical practices dating back to Galen and Hippocrates. A review of the history of the development of FFP may shed some light on current clinical practice and guide the direction of future investigations and therapies.

Clinical use of fresh-frozen plasma in neonatal intensive care unit

Recommendations for FFP use in neonates are based on a very limited amount of data, and not on well-designed randomized controlled trials. This retrospective study was performed to analyze our experience with FFP use in neonatal intensive care unit (NICU). From January 2006 until August 2011 a total of 80 neonates were identified as having been treated with FFP. The most common indication for FFP use was prolonged PT or aPTT, representing 32.8% of all usages of FFP. Following FFT treatment PT and aPTT normalized in 42% and 60% patients, respectively. Our results suggest that FFP were often used in acceptable indications in NICU.

Widespread use of fresh frozen plasma in US children's hospitals despite limited evidence demonstrating a beneficial effect

OBJECTIVES

To determine the pattern, prevalence and potential complications of fresh frozen plasma (FFP) use in US pediatric hospitals from 2002-2009.

STUDY DESIGN

Retrospective cohort study using the Pediatric Health Information System (PHIS) administrative database, which was queried for FFP admissions using diagnostic, procedural, and billing codes. Demographic data, daily use, and procedural codes were used to describe the patient population and pattern of FFP use.

RESULTS

Of 3 252 149 PHIS-recorded admissions, 2.85% had codes consistent with FFP use. This percentage did not change over the course of the study (P=.10). FFP was most commonly administered to children <1 year of age (54%), critically ill children (70%), and those with heart disease (34%). Fifteen percent of FFP-related admissions involved a thrombotic event. The overall mortality rate was 17% and it decreased during the study (P<.001). There was noteworthy variation in the proportion of FFP admissions among participating institutions.

CONCLUSIONS

FFP is commonly used in children admitted to PHIS hospitals. Despite recent expert recommendations highlighting the lack of efficacy in many clinical scenarios, the rate of FFP use does not appear to be changing. Randomized, controlled studies are needed to determine appropriate indications for FFP use and evaluate for potential complications.