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Heeger LE, Houben NAM, Caram-Deelder C, Fustolo-Gunnink SF, van der Bom JG, Lopriore E. Impact of restrictive platelet transfusion strategies on transfusion rates: A cohort study in very preterm infants. Transfusion 2024. [PMID: 38660945 DOI: 10.1111/trf.17844] [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: 11/21/2023] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Evidence supports a restrictive platelet transfusion threshold in preterm neonates. We aimed to describe the effect of implementing this threshold on transfusion rates. STUDY DESIGN AND METHODS This retrospective observational cohort study included all very preterm infants (born <32 weeks' gestation) admitted to a neonatal intensive care unit between 2004 and 2022, divided into three epochs. Platelet transfusion thresholds changed from 30 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2004 to December 2009) to 20 × 109/L for stable neonates and 50 × 109/L for unstable neonates (January 2010 to June 2019) to 25 × 109/L for non-bleeding neonates and 50 × 109/L for neonates with major bleeding (July 2019 to July 2022). The primary outcome was the percentage of transfused neonates in each epoch. Secondary outcomes included the median number of transfusions per neonate, the percentage of transfusions given above 25 or 50 × 109/L, and major bleeding and mortality rates. RESULTS The percentage of neonates transfused was 12.2% (115/939), 5.8% (96/1660), and 4.8% (25/525) in Epoch I, II, and III, respectively (p < .001), a relative reduction of 61%. The median number of transfusions per transfused neonate was 2.0 (interquartile range [IQR]: 1.0-3.0) in Epoch I, and 1.0 (IQR: 1.0-2.0) in subsequent Epochs (p = .04). The percentage of infants receiving at least one transfusion above 50 × 109/L in Epoch I, II, and III was 51.3% (59/115), 17.7% (17/96), and 20.0% (5/25; p < .001). Mortality and bleeding rates did not significantly differ between epochs. DISCUSSION Implementation of restrictive platelet guidelines led to reduction of the rate and number of platelet transfusions.
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Affiliation(s)
- L E Heeger
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - N A M Houben
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - C Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - S F Fustolo-Gunnink
- Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - J G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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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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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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Abstract
INTRODUCTION Thrombocytopaenia is one of the most common haemostatic abnormalities among neonates. It affects approximately one-quarter of neonates admitted into neonatal intensive care units and may lead to a high risk of bleeding and mortality, which are substantial causes for concern by neonatologists. Platelet transfusion (PT) is a specific treatment for thrombocytopaenia. To date, PT thresholds are diverse since the associations between low platelet count and negative outcomes are not clear. We propose this protocol for a systematic review to collect and assess evidence concerning the best PT threshold to reduce mortality, bleeding and major morbidity among neonates with thrombocytopaenia. METHODS AND ANALYSIS The systematic review will be performed according to the Cochrane Handbook for Systematic Review of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and the Grading of Recommendations Assessment, Development and Evaluation system. Two independent researchers will perform the study selection, data extraction/coding, quality assessment and further analyses of the included studies, with disagreements being resolved by a third researcher. A systematic search of the literature will be conducted in the PubMed, Cochrane Library and Embase databases from database inception through 13 October 2020. All randomised controlled trials, cohort studies and case-control studies will be included without any restrictions regarding publication date or language. The primary outcomes will comprise in-hospital mortality and bleeding episodes. Endnote X9 and Review Manager V.5.3 software will be used to manage the selection process and statistical analysis, respectively. If the included studies are sufficient and homogeneous for any of the outcomes, a quantitative synthesis (meta-analysis) may be performed. Otherwise, we will conduct a narrative systematic review of the results. ETHICS AND DISSEMINATION Ethical approval is not required for this study because the data will be obtained from published studies and will not include individual patient data. The results of this study are anticipated to be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42020169262.
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Affiliation(s)
- Dengjun Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Jinlin Wu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Yan Yue
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
| | - Jun Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Sichuan University, Chengdu, China
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Abstract
PURPOSE OF REVIEW In this review, we focus on three specific concepts related to platelet transfusion in the neonatal and pediatric population: choice of transfusion threshold; use of ABO-mismatched platelets; transfusion of pathogen-reduced or inactivated platelets. RECENT FINDINGS Recent trials support the use of lower platelet transfusion thresholds (25 000/μl) in preterm neonates, although data is limited to guide transfusion among more mature neonates. In children, there is low-level evidence as to what the prophylactic platelet transfusion threshold should be in many situations of thrombocytopenia, revealing major variability in platelet transfusion practices. Most pediatric guidelines are extrapolated from adult studies with the most evidence in treatment-associated hypoproliferative thrombocytopenia varying between a platelet transfusion threshold of 10 000/μl to 20 000/μl. Although pathogen-reduced platelets may lower the risks of transfusion-transmitted infection, the effects on platelet refractoriness and transfusion burden in this population warrant additional study. SUMMARY Our review highlights recent advances in neonatal and pediatric platelet transfusion and also emphasizes the urgent need for better evidence to guide practice given recent studies showing the potential harms of platelet transfusion, particularly with liberal use.
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Kim DH. Transfusion practice in neonates. KOREAN JOURNAL OF PEDIATRICS 2018; 61:265-270. [PMID: 30185018 PMCID: PMC6172519 DOI: 10.3345/kjp.2018.06849] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
Neonates, especially extremely low birth weight infants, are among the groups of patients undergoing transfusion frequently. Since they are exposed to higher specific transfusion risks compared to the patients of other age groups, there are many special aspects that must be considered for transfusion therapy in neonates. The transfusion risks in neonates include adverse outcomes specific for preterm infants as well as increased metabolic, immunologic, and infectious complications. To reduce the risks of transfusion-transmitted cytomegalovirus infection and transfusion-associated graft-versus-host disease, leukoreduced and irradiated cellular blood products should be used for all neonates. This review summarizes the risks of neonatal transfusion therapy, specific methods to reduce risk, and current trends and practices of red blood cell and platelet transfusions in neonates, to facilitate decision-making for neonatal transfusion.
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Affiliation(s)
- Do-Hyun Kim
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
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Nickel RS, Josephson CD. Neonatal Transfusion Medicine: Five Major Unanswered Research Questions for the Twenty-First Century. Clin Perinatol 2015; 42:499-513. [PMID: 26250913 DOI: 10.1016/j.clp.2015.04.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Blood component transfusions are important to the care of preterm neonates; however, their use in clinical practice often is not based on high levels of evidence. Five major questions for neonates are discussed: (1) What is the optimal red blood cell (RBC) transfusion threshold? (2) What is the optimal platelet transfusion threshold? (3) Does the storage age of an RBC unit affect outcomes? (4) Does RBC transfusion contribute to the pathogenesis of necrotizing enterocolitis? and (5) Which new practices should be used to prevent transfusion-transmitted infections? Although definitive answers to these questions do not exist, future research should help answer them.
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Affiliation(s)
- Robert Sheppard Nickel
- Department of Pediatrics, Children's National Health System, The George Washington University School of Medicine and Health Sciences, 111 Michigan Avenue North West, Washington, DC 20010, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Children's Healthcare of Atlanta, Emory University, 1405 Clifton Road North East, Atlanta, GA 30322, USA.
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