Neonatal transfusion practice

Transfusion strategies for neonates: current perspectives

Background

Blood transfusion intervention has been proven to be a crucial therapeutic aid for preterm infants with serious morbidities such as sepsis, intraventricular hemorrhage, and cardiopulmonary insufficiencies. However, blood transfusion practices have also been shown to cause significant adverse outcomes, which may negate the therapeutic effect of the intervention. To address the varying policies regarding the administration of blood products, healthcare professionals have adopted a consensus-based approach. The absence of a standard protocol has resulted in conflicting outcomes in previous clinical studies.

Objective

This study aimed to evaluate the effectiveness of blood transfusion practices in preterm infants by analyzing past clinical research and identifying the current trends that have emerged as a result of recent trials.

Results

Recent trials have demonstrated comparable trends in mortality rates and other primary outcomes, including retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, and brain injury, following transfusion of blood products in both groups. Nevertheless, employing restrictive thresholds rather than adopting a liberal approach can reduce these outcomes.

Conclusion

The current literature does not provide clear support for either technique as opposing and contradictory results are evident. However, there is a slight inclination toward the restrictive transfusion threshold due to recent trials, which warrants further in-depth investigation into this issue.

Platelet transfusion practice pattern before and after implementation of a local restrictive transfusion protocol in a neonatal intensive care unit

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.

Red blood cell transfusion practice in a single institution in Poland in 2018-2019 - Is there room for improvement?

INTRODUCTION

Red blood cell (RBC) transfusion (RBCT) is one of the most frequently performed procedures in inpatients within modern hospital systems. However transfusion practices may vary by an institution or even by a prescribing physician. In order to assess the current RBCT practice in our institution, we performed a detailed analysis of RBCTs.

MATERIAL AND METHODS

We performed a retrospective analysis of all RBCTs in our institution between January 2018 and December 2019. The data collected included: age, sex, type of RBC, number of single and multiple unit RBCTs in bleeding and nonbleeding patients, number of multiple unit RBCTs in non-bleeding patients with and without hemoglobin (Hb) concentration determination after each RBC, primary indication for RBCT, pre-post RBCT Hb concentration in non-bleeding patients, lactate concentration pre-post RBCT in non-bleeding patients.

RESULTS

The indications for RBCT were anemia (2244, 56.2 % RBC) and bleeding (1463, 36.6 % RBC). The most frequently used types of RBCs were RBCs without buffy coat (75.1 %) and leucodepleted RBCs (20.9 %). In non-bleeding patients 45.7 % were multiple unit RBCTs, only 3% were performed with Hb determination following the first unit of RBC, 508 (20.2 %) RBCT were performed with pre-post RBCT lactate concentration determination.

CONCLUSIONS

Analysis of the local RBCT practice showed significant room for improvement. Areas of concern were type of RBC ordered, multiple unit transfusions in non-bleeding patients, lack of laboratory control of oxygenation pre-post transfusion or not taking it into account in RBCT decision making. Deficiencies are planned to be addressed by a comprehensive blood utilization review programme.

Massive Gastric Hemorrhage after Indomethacin Therapy: A Rare Presentation and Critical Management in an Extremely Preterm Infant

Indomethacin has been widely used in preterm infants with hemodynamically significant patent ductus arteriosus (PDA). Gastrointestinal complications of indomethacin have been reported in 5% of treated neonates. However, massive gastric mucosa hemorrhage is a rarely reported complication. To the best of our knowledge, the infant in this report is the smallest reported in the literature to have undergone successful surgery for such a complication. A male preterm infant weighing 566 g was born at 25^2/7 weeks of gestational age without a complicated maternal history. Soon after birth, he received nasal noninvasive respiratory support and minimal feeding. PDA was observed since the first day of life (DOL), treatments were initiated on the second DOL for the hemodynamical significance, and PDA was closed after two courses of indomethacin therapy (0.2 mg/kg). At midnight on the seventh DOL, generalized pallor, bloody gastric drainage, and a distended stomach were observed. Massive gastric bleeding was suspected. He suffered from intermittent hypotension, which was corrected with blood products and fluid resuscitation under monitoring with a radial arterial line. Gastric lavage with cooling saline was performed twice but in vain. Prior to surgical consultation, intravascular volume transfusion was given twice. An exploratory laparotomy was arranged after obtaining the parents' consent. Blood oozing from the gastric mucosa was observed through gastrostomy and was successfully stopped via epinephrine-soaked gauze compression. After the operation, his clinical course remained uneventful, and he was discharged without neurological anomaly at two-year follow-up. Physicians need to be cautious of indomethacin's effect on platelet dysfunction in preterm infants with multiple predisposing factors. The tendency for mucosal bleeding should be continuously monitored after indomethacin therapy.

Assessment of a downsized potassium adsorption filter designed to transfuse neonates

BACKGROUND

During storage, the potassium level of red blood cell (RBC) components increases, especially after irradiation. Neonates are prone to hyperkalemia, for example, non-oliguric hyperkalemia, so using potassium adsorption filters during transfusion may be helpful. To overcome dilution of RBC components caused by saline priming of existing potassium adsorption filters, a downsized potassium adsorption filter for neonates (PAF-n, Kawasumi Laboratories Inc., Tokyo, Japan) was developed.

STUDY DESIGN AND METHODS

To assess the performance of PAF-n, its adsorption efficiency and RBC recovery rate were evaluated by testing pre-filtration and serial post-filtration (0-30 mL, 30-60 mL, 60-90 mL, and 90-120 mL) samples from 8 RBC components.

RESULTS

The average potassium adsorption rate of the PAF-n was 90.5% ± 0.78%, and never less than 89.0% in any of 8 RBC components. RBC recovery rates were 99.3% ± 1.12%.

CONCLUSION

The PAF-n showed an effective potassium ability with negligible RBC dilution.

Management of neonatal thrombocytopenia in a context of maternal antiplatelet alloimmunization: Expert opinion of the French-speaking working group

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a potentially devastating disease, seen in 1/800-1000 neonates. FNAIT is the most common cause of early-onset isolated severe neonatal thrombocytopenia in maternity wards. The most feared complication of this disorder is intracranial hemorrhage, leading to death or neurological sequelae. There is no systematic screening of at-risk pregnancies and FNAIT is often discovered when fetal or neonatal bleeding is observed. A working group on fetomaternal platelet alloimmunization was created in 2017, under the auspices on the French Group of Thrombosis and Hemostasis (GFHT). The first objective of this group was to survey clinical practices for treatment of thrombocytopenic neonates in a context of suspected or confirmed FNAIT.

Duration of anaemia during the first week of life is an independent risk factor for retinopathy of prematurity

AIM

This study evaluated the correlation between retinopathy of prematurity (ROP), anaemia and blood transfusions in extremely preterm infants.

METHODS

We included 227 infants born below 28 weeks of gestation at King Edward Memorial Hospital, Perth, Australia, from 2014-2016. Birth characteristics and risk factors for ROP were retrieved, and anaemia and severe anaemia were defined as a haemoglobins of <110 g/L and <80 g/L, respectively. Logistic regression was used for the analysis.

RESULTS

Retinopathy of prematurity treatment was needed in 11% of cases and the mean number of blood transfusions (p < 0.01), and mean number of weeks of anaemia (p < 0.001) and of severe anaemia (p < 0.05), had positive associations with ROP cases warranting treatment. In the multivariate logistic regression analysis, the best-fit model of risk factors included anaemic days during first week of life, with an odds ratio (OR) of 1.46% and 95% confidence interval (CI) of 1.16-1.83 (p < 0.05), sepsis during the first 4 weeks of life (OR 3.14, 95% CI 1.10-9.00, p < 0.05) and days of ventilation (OR 1.03, 95% CI 1.01-1.06, p < 0.05).

CONCLUSION

The duration of anaemia during the first week of life was an independent risk factor for ROP warranting treatment and preventing early anaemia may decrease this risk.

Utilization of frozen plasma, cryoprecipitate, and recombinant factor VIIa for children with hemostatic impairments: An audit of transfusion appropriateness

BACKGROUND

Blood transfusions and fractionated products are not without risk and may lead to acute and long-term adverse events. The objective of this study was to evaluate the appropriateness of usage of frozen plasma (FP), cryoprecipitate (CRYO), and recombinant factor VIIa (rVIIa) in a pediatric setting.

METHODS

All orders for FP, CRYO, and rVIIa were prospectively audited over 6 weeks. Data collected included demographics, laboratory values, indication, and adverse reactions. The appropriateness of each order was independently evaluated using adjudication criteria rated by two hematologists.

RESULTS

Two hundred sixty-five products were ordered; 67% of the orders were issued to operating rooms or intensive care units. The most common indication for all products was cardiac surgery. FP was ordered as fluid replacement (15/215; 7%) to correct abnormal coagulation tests (23/215; 11%) and for patients with minor or no bleeding (111/242; 46%). FP was more likely to alter the international normalized ratio (INR) if the INR was over 2.0 (P < 0.0001). The rate of inappropriate products was judged as FP 19%, CRYO 21%, and rVIIa 91%.

CONCLUSION

FP, CRYO, and rVIIa are most commonly used in the operating room and intensive care units. FP was often used for fluid resuscitation and for patients with mild to no bleeding. FP was only effective in lowering the INR when the INR was over 2.0. Use of rVIIa was rarely ordered for an appropriate indication. Results of this study inform its readers where trials of pediatric transfusion should be performed to clarify how these products should be used in clinical practice.

Transfusion support in preterm neonates <1500 g and/or <32 weeks in a tertiary care center: A descriptive study

BACKGROUND:

Lack of recent studies focusing on indications, pattern, and benefits of transfusions in low birth weight (B.Wt) and low gestational age (GA) preterm neonates prompted us to undertake this study.

AIM:

To estimate the transfusion requirements and outcomes in preterm neonates <1500 g and/or <32 weeks.

SETTINGS AND DESIGN:

This is a cross-sectional study conducted over a period of 2 years in a tertiary care center.

MATERIALS AND METHODS:

This study was conducted with 101 preterm neonates <1500 g and/or <32 weeks who received blood transfusions in the Neonatal Intensive Care Unit. Restrictive pattern of transfusion was followed. Demographic details and antenatal, neonatal, laboratory, and transfusion parameters were collected.

STATISTICAL ANALYSIS USED:

Statistical analyses were performed using SPSS 16.

RESULTS:

The study participants received 311 transfusions. Transfusion requirements decreased with increasing GA and B.Wt. Majority of blood transfusions occurred during the first 2 weeks of life. Packed red blood cells (PRBCs) were the most frequent blood components transfused. Ninety-six percent of the study population had an uneventful transfusion. Mean hemoglobin improvement after PRBC transfusions was 2.3 ± 2.1 g/dl. Improvement in apnea occurred in 76% PRBC transfusions. Infants with sepsis, patent ductus arteriosus, bronchopulmonary dysplasia, disseminated intravascular coagulation, and dyselectrolytemia received more number of transfusions.

CONCLUSION:

This study would serve as an audit for neonatal blood transfusion therapy. Close adherence to neonatal transfusion policy and restrictive transfusion guidelines helps reduce inappropriate use of blood products and adverse transfusion reactions.

Comparison of neonatal red cell transfusion reporting in neonatal intensive care units with blood product issue data: a validation study

BACKGROUND

Infants in Neonatal Intensive Care Units represent a heavily transfused population, and are the focus of much research interest. Such research commonly relies on custom research databases or routinely collected data. Knowledge of the accuracy of transfusion recording in these databases is important. This study aims to assess the reporting of red blood cell transfusion neonatal intensive care unit data compared with routinely collected hospital blood bank ("Blood Watch") data.

METHODS

Blood Watch data was linked with the NICUS Data Collection, and with routinely collected birth and hospital data for births between 2007 and 2010. The sensitivity, specificity, and positive and negative predictive values for transfusion were calculated, compared to the Blood Watch data. The agreement between the NICUS and Blood Watch datasets on quantity transfused was also assessed.

RESULTS

Data was available on 3934 infants, of which 16.2% were transfused. Transfusion was reported in the NICUS Data Collection with high specificity (98.3%, 95% confidence interval (97.8%,98.7%)), but with some under-enumeration (sensitivity 89.2% (95% CI 86.5%,91.5%)). There was excellent agreement between the NICUS and Blood Watch datasets on quantity transfused (Kappa 0.90, 95% CI (0.88,0.92)). Transfusion reporting in the hospital data for these infants was also reliably reported (Sensitivity 83.7% (95% CI 80.6%,86.5%), specificity 99.1% (95% CI 98.7%,99.4%)).

CONCLUSIONS

Transfusion is reliably reported in the neonatal intensive care unit data, with some under-reporting, and quantity transfused is well recorded. The NICUS Data Collection provides useful information on blood transfusions, including quantity of blood transfused in a high risk population.

The Effects of red Blood Cell Transfusion on Tissue Oxygenation and the Microcirculation in the Intensive Care Unit: A Systematic Review

The transfusion of red blood cells (RBCs) is a common intervention in intensive care unit (ICU) patients, yet the benefits are far from clear in patients with moderate anemia (eg, hemoglobin (Hb) levels of 7-10 g/dL). Determining which of these patients benefit, and how to even define benefit, from transfusion is challenging. As the intended physiological benefit underpinning RBC transfusion is to improve tissue oxygenation, several studies utilizing a wide range of assessment techniques have attempted to study the effects of transfusion on tissue oxygenation and microcirculatory function. The objective of this systematic review was to determine whether RBC transfusion improves tissue oxygenation/microcirculatory indices in the ICU population, and to provide an introduction to the techniques used in these studies. Eligible studies published between January 1996 and February 2017 were identified from searches of PubMed, Embase, Cinahl, ScienceDirect, Web of Science, and The Cochrane Library. Seventeen studies met inclusion criteria, though there was significant heterogeneity in study design, patient population, assessment techniques and outcomes reported. Overall, the majority of studies (11 of 17) concluded that transfusion did not generally improve tissue oxygenation or microcirculation. Inter-individual effects were highly variable, however, and closer review of sub-groups available in 9 studies revealed that patients with abnormal tissue oxygenation or microcirculatory indices prior to transfusion had improvement in these indices with transfusion, irrespective of assessment method. This finding suggests a new strategy for future trials in the ICU: utilizing tissue oxygenation/microcirculatory parameters to determine the need for transfusion rather than largely arbitrary hemoglobin concentrations.

Revisiting the Criteria for Exchange Transfusion for Severe Neonatal Hyperbilirubinemia in Resource-Limited Settings

BACKGROUND

Exchange transfusion (ET) for severe neonatal hyperbilirubinemia (SNH) is frequently undertaken in low- and middle-income countries (LMIC), in sharp contrast to the prevailing practice in high-income countries. However, the criteria for initiating this procedure in settings with limited resources for treating infants with SNH have not been systematically explored.

OBJECTIVE

To identify key considerations for initiating ET in resource-poor countries to curtail its unnecessary use for the prevention of kernicterus.

METHODS

A review of the existing guidelines and literature on the management of neonatal hyperbilirubinemia worldwide was conducted to identify criteria and underlying factors for initiating ET.

RESULTS

There is a dearth of evidence from randomized clinical trials to support clear criteria for indicated ET worldwide. Because risk assessment for kernicterus based solely on the levels of total serum bilirubin (TSB) has often proved inadequate, a combination of plasma/serum bilirubin estimation and clinical evaluation for acute bilirubin encephalopathy (ABE) has been recommended for predicting the risk of kernicterus. However, there is a lack of consistency regarding the TSB levels for which ET should be initiated in relation to the clinical signs/symptoms of ABE and hemolytic disorders.

CONCLUSIONS

A decision-making framework that combines TSB thresholds and evidence of neurotoxicity is needed for evaluating the risk of kernicterus and prioritising infants for ET in LMICs to curtail unnecessary interventions.

Evaluation of a simple intervention to reduce exchange transfusion rates among inborn and outborn neonates in Myanmar, comparing pre- and post-intervention rates

Background

In Myanmar, approximately half of all neonatal hospital admissions are for hyperbilirubinaemia, and tertiary facilities report high rates of Exchange Transfusion (ET). The aim of this study was to evaluate the effectiveness of the pilot program in reducing ET, separately of inborn and outborn neonates.

Methods

The study was conducted in the Neonatal Care Units of four national tertiary hospitals: two exclusively treating inborn neonates, and two solely for outborn neonates. Prior to intervention, no high intensity phototherapy was available in these units. Intervention in late November 2011 comprised, for each hospital, provision of two high intensity LED phototherapy machines, a photo radiometer, and training of personnel. Hospital-specific data were assessed as Relative Risk (RR) ratios comparing ET rates pre- and post-intervention, and individual hospital results were pooled when appropriate.

Results

In 2011, there were 118 ETs among inborn neonates and 140 ETs among outborn neonates. The ET rate was unchanged at Inborn Hospital A (RR = 1.07; 95 % CI: 0.80–1.43; p = 0.67), and reduced by 69 % at Inborn Hospital B (RR = 0.31; 95 % CI: 0.17–0.57; p < 0.0001). For outborn neonates, the pooled estimate indicated that ET rates reduced by 33 % post-intervention (RR_MH = 0.67; 95 % CI: 0.52–0.87; p = 0.002); heterogeneity was not a problem.

Conclusion

Together with a photoradiometer and education, intensive phototherapy can significantly reduce the ET rate. Inborn Hospital A had four times as many admissions for jaundice as Inborn Hospital B, and did not reduce ET until it received additional high intensity machines. The results highlight the importance of providing enough intensive phototherapy units to treat all neonates requiring high intensity treatment for a full course.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12615001171505, 2 November 2015.

Malaria and blood transfusion: major issues of blood safety in malaria-endemic countries and strategies for mitigating the risk of Plasmodium parasites

Malaria inflicts humankind over centuries, and it remains as a major threat to both clinical medicine and public health worldwide. Though hemotherapy is a life-sustaining modality, it continues to be a possible source of disease transmission. Hence, hemovigilance is a matter of grave concern in the malaria-prone third-world countries. In order to pursue an effective research on hemovigilance, a comprehensive search has been conducted by using the premier academic-scientific databases, WHO documents, and English-language search engines. One hundred two appropriate articles were chosen for data extraction, with a particular reference to emerging pathogens transmitted through blood transfusion, specifically malaria. Blood donation screening is done through microscopic examination and immunological assays to improve the safety of blood products by detection major blood-borne pathogens, viz., HIV, HBV, HCV, syphilis, and malarial parasites. Transfusion therapy significantly dwindles the preventable morbidity and mortality attributed to various illnesses and diseases, particularly AIDS, tuberculosis, and malaria. Examination of thick and thin blood smears are performed to detect positivity and to identify the Plasmodium species, respectively. However, all of these existing diagnostic tools have their own limitations in terms of sensitivity, specificity, cost-effectiveness, and lack of resources and skilled personnel. Globally, despite the mandate need of screening blood and its components according to the blood-establishment protocols, it is seldom practiced in the low-income/poverty-stricken settings. In addition, each and every single phase of transfusion chain carries sizable inherent risks from donors to recipients. Interestingly, opportunities also lie ahead to enhance the safety of blood-supply chain and patients. It can be achieved through sustainable blood-management strategies like (1) appropriate usage of precise diagnostic tools/techniques, (2) promoting hemovigilance system, and (3) adopting novel processes of inactivation technology. Furthermore, selection of the zero-risk donors could pave the way to build a transmissible malaria-free world in the near future.

Citrate metabolism in blood transfusions and its relationship due to metabolic alkalosis and respiratory acidosis

Metabolic alkalosis commonly results from excessive hydrochloric acid (HCl), potassium (K(+)) and water (H2O) loss from the stomach or through the urine. The plasma anion gap increases in non-hypoproteinemic metabolic alkalosis due to an increased negative charge equivalent on albumin and the free ionized calcium (Ca(++)) content of plasma decreases. The mean citrate load in all patients was 8740±7027 mg from 6937±6603 mL of transfused blood products. The citrate load was significantly higher in patients with alkalosis (9164±4870 vs. 7809±3967, P < 0.05). The estimated mean total citrate administered via blood and blood products was calculated as 43.2±34.19 mg/kilogram/day. In non-massive and frequent blood transfusions, the elevated carbon dioxide output has been shown to occur. Due to citrate metabolism causes intracellular acidosis. As a result of intracellular acidosis compensation, decompensated metabolic alkalosis + respiratory acidosis and electrolyte imbalance may develop, blood transfusions may result in certain complications.

Restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants: a systematic review and meta-analysis

AIM

A systematic review was conducted to examine the effects of restrictive versus liberal red blood cell (RBC) transfusion thresholds on clinically important outcomes in very low birth weight (VLBW) infants.

METHODS

Randomised controlled trials (RCTs) of varying RBC transfusion thresholds in VLBW infants were identified by searching MEDLINE, EMBASE, CINAHL, all of the Cochrane Library and other supplementary sources. Selected studies included one of the following outcomes: total number of red blood cell transfusions, donor exposure rate, cranial ultrasonographically diagnosed brain injury, retinopathy of prematurity, bronchopulmonary dysplasia, necrotising enterocolitis or death. Studies to be included were selected by two reviewers who also assessed the risk of bias of each trial. Data extraction and analyses were independently performed by two reviewers. All data were analysed using RevMan 5.

RESULTS

Six RCTs were identified. One trial did not meet the inclusion criteria, while two had inadequate methodological quality. Pooled analysis of two trials showed that the restrictive transfusion group received a significantly lower mean number of transfusions per infant (mean difference (MD) -1.35, 95% confidence interval (CI) [-2.61, -0.09]) and donor exposure rate (MD -0.54, 95% CI [-0.93, -0.15]). No other statistically significant differences were observed.

CONCLUSION

Restrictive RBC transfusion thresholds in VLBW infants may be utilised without incurring clinically important increases in the risk of death or major short-term neonatal morbidities.

A randomized trial of platelet transfusions over 30 vs 120 minutes: is there an effect on post-transfusion platelet counts?

OBJECTIVE

To determine whether platelet infusion time affects platelet counts in thrombocytopenic newborns.

STUDY DESIGN

This was a prospective randomized control study of 43 platelet transfusions given to newborns. Transfusions were randomized to run over either 30 min or 2 h. Platelet counts taken 30 min and 6 h after transfusion were compared using parametric, nonparametric, Pearson's correlation and logistic regression.

RESULT

Changes in platelet counts 30 min and 6 h after transfusion were not different between the groups. Weak but significant negative correlations existed between postmenstrual age and change in platelet count at 30 min (r=-0.33, P=0.04) and 6 h (r=-0.37, P=0.018) after transfusion. There were no differences between the mean blood pressures before and after transfusion in either group.

CONCLUSION

Transfusion duration does not affect post-transfusion platelet counts in newborns. Babies of lower postmenstrual age (PMA) may have better responses to platelet transfusions. Finally, platelet transfusions over both durations are well tolerated in neonates.

Anemia and transfusion in critically ill pediatric patients: a review of etiology, management, and outcomes

This article describes the incidence and etiology of anemia in critically ill children. In addition, the article details the pathophysiology and clinical ramifications of anemia in this population. The use of transfused packed red blood cells as a therapy for anemia in critically ill patients is also discussed, including the indications for and complications associated with this practice as well as potential reasons for these complications. Finally, the article lists some therapeutic practices that may lessen the risks associated with transfusion, and briefly discusses the use of blood substitutes.

Maintenance of storage properties of pediatric aliquots of apheresis platelets in fluoroethylene propylene containers

BACKGROUND

Platelet (PLT) aliquots for pediatric use have been shown to retain in vitro properties when stored in gas-impermeable syringes for up to 6 hours. As an alternative, PLT aliquots can be stored for longer periods in containers used for storage of whole blood-derived PLTs. These containers are not available separate from whole blood collection sets and PLT volumes less than 35 mL either have not been evaluated or may be unsuitable for PLT storage. Gas-permeable fluoroethylene propylene (FEP) containers have been used in the storage of cell therapy preparations and are available in multiple sizes as single containers but have not been evaluated for PLT storage.

STUDY DESIGN AND METHODS

A single apheresis unit was divided on Day 3 into small aliquots with volume ranging from 20 to 60 mL, transferred using a sterile connection device, and stored for an additional 2 days either in CLX (control) or in FEP containers. PLT storage properties of PLTs stored in FEP containers were compared to those stored in CLX containers. Standard PLT in vitro assays were performed (n =6).

RESULTS

PLT storage properties were either similar to those of CLX containers or differed by less than 20% excepting carbon dioxide levels, which varied less than 60%.

CONCLUSION

Pediatric PLT aliquots of 20, 30, and 60mL transferred on Day 3 into FEP cell culture containers adequately maintain PLT properties for an additional 2days of storage.

The 'Effects of Transfusion Thresholds on Neurocognitive Outcome of Extremely Low Birth-Weight Infants (ETTNO)' Study: Background, Aims, and Study Protocol

Background: Infants with extremely low birth weight uniformly develop anemia of prematurity and frequently require red blood cell transfusions (RBCTs). Although RBCT is widely practiced, the indications remain controversial in the absence of conclusive data on the long-term effects of RBCT. Objectives: To summarize the current equipoise and to outline the study protocol of the 'Effects of Transfusion Thresholds on Neurocognitive Outcome of extremely low birth-weight infants (ETTNO)' study. Methods: Review of the literature and design of a large pragmatic randomized controlled trial of restrictive versus liberal RBCT guidelines enrolling 920 infants with birth weights of 400-999 g with long-term neurodevelopmental follow-up. Results and Conclusions: The results of ETTNO will provide definite data about the efficacy and safety of restrictive versus liberal RBCT guidelines in very preterm infants.

[Evaluation of the concordance between guidelines and transfusion practices in neonatal intensive care units]

OBJECTIVE

To assess the concordance rate between the prescriptions of blood products and Afssaps guidelines for transfusion practices in neonatology.

STUDY DESIGN

Retrospective monocentric study.

PATIENTS AND METHODS

Children transfused in the neonatology intensive care units in the Universitary Hospital of Rouen were included. Concordance rates between transfusion prescriptions, delivered and transfused products and the Afssaps guidelines were assessed. Any additional costs resulting from a theoretical discordance was also assessed.

RESULTS

In 2006, 380 PSL were administered to 168 newborn children (NBC). Packed red blood cells (PRBC) represented the most often transfused products (n=290, 76%). Fifty packed platelets (PP) were transfused (13% of the blood products) and 41 fresh frozen plasmas (11%). Overall concordance rate between the Afssaps guidelines and the prescriptions was 64.9%. In 35.1% of cases, the prescription was excessive, compared to the recommendations. Excessive transfusion represented a total of 27,307 euros.

CONCLUSION

Global concordance's rate between the guidelines and the prescriptions is fairly well. PRBC are the most blood product transfused. Excessive transfusions related to this concordance rate are leading to important theoretical costs. New informations to the guidelines are warranted to improve transfusional practices in this institution.

In vivo effect of recombinant human granulocyte colony-stimulating factor on neutrophilic expression of CD11b in septic neonates: a randomized controlled trial

Neonates are susceptible to septicemia secondary to quantitative and qualitative neutrophilic defects. Granulocyte colony-stimulating factor (G-CSF) stimulates myeloid progenitor cell proliferation and induces selective neutrophil functions. The authors aimed to evaluate the effect of G-CSF administration in septic neonates on neutrophil production and CD11b expression. Sixty septic neonates were randomized to receive intravenous G-CSF 10 μg/kg/day for 3 days (G-CSF group, n = 30), or not to receive G-CSF (non-G-CSF group, n = 30). Thirty healthy newborns were included as controls. Laboratory investigations included complete blood count, C-reactive protein, blood culture, renal and liver function tests, and assessment of neutrophilic expression of CD11b. Total leukocytes count (TLC), absolute neutrophil count (ANC), and immature myeloid cell count in G-CSF group showed significant difference between post-and pre-G-CSF levels. TLC, ANC, immature myeloid cell count and immature/total myeloid cells ratio were higher in G-CSF group compared to non-G-CSF group on days 1 and 3. Higher neutrophilic expression of CD11b was reported in both septic groups on day 0 compared to control group. On day 5, CD11b was higher in G-CSF group than non-G-CSF group. G-CSF improved CD11b% in neutropenic and non-neutropenic septic neonates. No significant difference was found between pre- and posttreatment renal and liver function tests. Lower duration of antibiotic intake and hospitalization was observed in G-CSF group compared to non-G-CSF group. G-CSF administration as an adjuvant therapy for neonatal septicemia, whether neutropenic or not, improves neutrophilic count and function and contributed to early healing from sepsis.

Implementation of a multi-parameter Point-of-Care-blood test analyzer reduces central laboratory testing and need for blood transfusions in very low birth weight infants

Blood sampling for laboratory testing is a major cause of iatrogenic blood loss and anemia in neonatal intensive care unit [NICU] patients. The objective of the study was to assess whether the implementation of a multi-parameter Point of Care Test [POCT] (Roche, Cobas b221) analyzer affected blood loss for central laboratory testing and need for red blood cell transfusion in our NICU. This was a retrospective observational cohort study in a NICU with comparison of two serial cohorts of 2 years each. Implementation of a multi-parameter POCT decreased central laboratory performed testing for bilirubin (-32% per patient) and electrolytes (-36% per patient). On average, the net blood volume taken per admitted patient for electrolyte testing decreased with 23.7% and 22.2% for bilirubin testing in the second cohort. After implementation of POCT, fewer very low birth weight infants [VLBWI] required blood transfusion (38.9% vs. 50%, p<.05) as the number of transfusion/infants decreased by 48% (1.57 vs. 2.53, p<0.01). The implementation of POCT was cost-efficient for the Belgian national health insurance, cost reduction -8.3% per neonate. We conclude that implementation of a bedside multi-parameter POCT analyzer decreases transfusions among VLBWI by reducing iatrogenic blood loss for central laboratory testing.

Storage of aliquots of apheresis platelets for neonatal use in syringes with and without agitation

BACKGROUND

To facilitate volume control in neonates, platelets (PLTs) are aliquoted and stored for short periods in non-gas-permeable syringes before infusion. Although agitation of PLTs during storage in gas-permeable bags is performed to maintain their quality, the effect of syringe agitation during storage is unknown.

STUDY DESIGN AND METHODS

Double apheresis PLTs (n = 6) were collected and split, providing two identical products. On Days 2 and 4 of storage, aliquots from one bag of each pair were transferred to two syringes and stored for 6 hours on flatbed agitator or were left at 20 to 24 °C without agitation. A series of in vitro tests was performed on Days 0, 2 (Hours 0 and 6), and 4 (Hours 0 and 6). Control samples were obtained from the second matched bag that was stored on the agitator. Data were analyzed by one-way analysis of variance with differences considered significant if the p value was less than 0.05.

RESULTS

Comparable results for several PLT variables were obtained with or without agitation of the syringes. On Day 4 Hour 6, pH values were 7.18 ± 0.12 (agitated syringes) and 7.19 ± 0.1 (nonagitated syringes), and extent of shape change and hypotonic shock response measurements were not significantly different between agitated syringes and nonagitated syringes (23.7 ± 6.4 and 74.3 ± 9.8% vs. 23.3 ± 5.4 and 76.0 ± 7.6%), respectively.

CONCLUSION

Based on in vitro testing, apheresis PLT aliquots can be stored in syringes for at least 6 hours without agitation before transfusions.

Neonatal red blood cell transfusions: searching for better guidelines

BACKGROUND

Packed red blood cell (RBC) transfusions are often administered to patients in the neonatal intensive care unit. The purpose of this study was to determine whether current blood transfusion guidelines are as useful as care givers' perception in identifying patients in need of a packed RBC transfusion.

DESIGN AND METHODS

Health care providers were asked to complete a pre- and post-transfusion survey on neonates receiving a packed RBC transfusion. These patients were divided into three groups based on reasons for transfusion: (i) guidelines; (ii) care-givers' perceptions of need for packed RBC transfusion; or (iii) both. These three groups were further subdivided into two cohorts according to whether they had a clinical improvement or not. Demographic data and clinical variables were compared between the groups.

RESULTS

Seventy-eight care-givers were surveyed. Eighteen patients (23%) were transfused based on guidelines, 36 (46%) based on care givers' perception and 24 (31%) based on both. Neonates transfused based on guidelines alone were more likely to have received the transfusion in the first week of life, had a higher pre-transfusion haematocrit, were less symptomatic and had a higher trend to require mechanical ventilation. Neonates transfused based on caregivers' perception were more likely to be on non-invasive ventilatory support and were more symptomatic. Neonates who improved after a transfusion had a lower pre-transfusion haematocrit (p=0.02), were more symptomatic (p=0.01) and were more likely to be on non-invasive ventilatory support (p=0.002) when compared to the group without a clinical improvement. The group without improvement had an increase in oxygen requirement (+2.8±6.4) after the transfusion (p=0.0004). Tachycardia was the most sensitive predictor of a benefit from packed RBC transfusion [OR 6.48: p=0.005].

DISCUSSION

Guidelines on when to transfuse stable growing neonates with packed RBC should be re-evaluated to include more care giver judgement and perhaps be more restrictive for critically ill neonates.

Very low birth weight infants qualifying for a 'late' erythrocyte transfusion: does giving darbepoetin along with the transfusion counteract the transfusion's erythropoietic suppression?

OBJECTIVE

Red blood cell (RBC) transfusions can suppress erythropoiesis. On this basis, RBC transfusions administered to very low birth weight (VLBW) neonates potentially render them more likely to qualify for a subsequent transfusion.

STUDY DESIGN

We hypothesized that 'late' (>14 days after birth) RBC transfusions given to VLBW neonates result in a decrease in reticulocyte count persisting for at least 7 to 10 days. We also hypothesized that a single dose of darbepoetin given along with the transfusion would have the opposite effect, increasing the reticulocyte count for at least 7 to 10 days. To test this, we conducted a single-centered randomized trial with 20 VLBW neonates who, according to our transfusion guidelines, qualified for a late transfusion.

RESULT

VLBW infants about to receive a late RBC transfusion were randomized (1:1) to also receive vs not receive (controls) a single subcutaneous dose of darbepoetin (10 μg kg(-1)). Reticulocyte counts diminished significantly in the controls (a drop of 85±62 × 10(3) μl(-1) (mean±s.d.) at 7 to 10 days), but increased significantly in the darbepoetin recipients (an increase of 177±120 × 10(3) μl(-1) at 7 to 10 days, P<0.0001). At 7 to 10 days after the transfusion, hematocrits of the controls were 8.1±4.9 points above their pre-transfusion values and of the darbepoetin group were 12.4±2.7 points above their pre-transfusion values (P=0.033).

CONCLUSION

This was a limited-scope, single-centered, randomized trial intended to pilot-test a new concept in neonatal transfusion practice. Namely, we tested whether a late RBC transfusion suppressed reticulocytosis and whether a concomitant single dose of darbepoetin counteracted that suppression. Using the pilot data presented in this study, larger trials can now be designed to address meaningful clinical outcomes such as transfusion avoidance using this approach.

Neurocognitive profiles of preterm infants randomly assigned to lower or higher hematocrit thresholds for transfusion

OBJECTIVE

Preterm infants are frequently transfused with red blood cells based on standardized guidelines or clinical concerns that anemia taxes infants' physiological compensatory mechanisms and thereby threatens their health and well-being. The impact of various transfusion guidelines on long-term neurocognitive outcome is not known. The purpose of this study is to evaluate long-term neurocognitive outcome on children born prematurely and treated at birth with different transfusion guidelines.

METHODS

Neurocognitive outcomes were examined at school age for 56 preterm infants randomly assigned to a liberal (n = 33) or restrictive (n = 23) transfusion strategy. Tests of intelligence, achievement, language, visual-spatial/motor, and memory skills were administered. Between-group differences were assessed.

RESULTS

Those in the liberal transfusion group performed more poorly than those in the restrictive group on measures of associative verbal fluency, visual memory, and reading.

CONCLUSIONS

Findings highlight possible long-term neurodevelopmental consequences of maintaining higher hematocrit levels.

Iron supplementation for preterm infants receiving restrictive red blood cell transfusions: reassessment of practice safety

OBJECTIVE

To reassess iron supplementation practice safety in very low birth weight (VLBW) preterm infants receiving restrictive red blood cell transfusions during initial hospitalization.

STUDY DESIGN

Iron status, including hemoglobin (Hb), serum iron, ferritin, and soluble transferrin receptor (sTfR) levels and reticulocyte count of transfused (n=236) and non-transfused (n=166) preterm infants at ≤24 h and 2, 4 and 8 weeks were recorded. As per protocol, a restrictive blood transfusion policy and supplementation of 5 mg kg(-1) per day of iron polymaltose complex from 4 weeks and 25 mg(-1) per day of vitamin E from 2 weeks were imposed for all infants. Normative reference cord-blood ferritin value of preterm infants was used for comparison. Vitamin E levels and incidence of morbidities associated with prematurity were recorded.

RESULT

At ≤24 h, the characteristics and iron status of both groups were similar. At 2, 4 and 8 weeks, the transfused group had significantly higher Hb, iron and ferritin levels; sTfR levels were lower at 4 and 8 weeks (all indices, P<0.05). At 8 weeks, the median ferritin levels of our transfused group were lower than that of normative reference cord-blood value (115 (50th percentile) vs 79 (43 to 107) μg l(-1), respectively). Vitamin E levels and the incidence of morbidities associated with prematurity of the transfused and non-transfused groups were not different (both indices, P>0.18).

CONCLUSION

Adding iron supplementation to preterm infants receiving restrictive blood transfusions has shown to be a judicious and safe practice in terms of iron status for VLBW preterm infants.

Thrombopoietin following transfusion of platelets in preterm neonates

Thrombocytopenia is common in the neonatal intensive care unit. Transfusion of platelets is often required. The purpose of our study was to determine changes in thrombopoietin (Tpo) following transfusion of platelets in preterm neonates. Preterm neonates undergoing platelet transfusion were randomized to receive a transfusion volume of either 10 or 15 ml/kg. Blood was obtained for Tpo measurement pre-transfusion, one and 24 hours post-transfusion. Platelet Factor 4 (PF4) was also measured to quantify platelet activation. Statistical analysis was performed using repeated measures ANOVA, and Mann-Whitney U test as appropriate. Ten infants were enrolled in each group. Gestational age, birth weight, etiology of thrombocytopenia, and timing of transfusion did not differ between the 10 and 15 ml/kg groups. There were no differences between the groups in platelet count prior to and/or following transfusion. Both transfusion volumes were equally well tolerated. Tpo and PF4 did not differ between groups at any of the study time points. When both groups were analysed together, Tpo dropped 43% (95% confidence 37-49%, p = 0.01) 1-hour post compared to pre-transfusion. In conclusion the observed decrease in Tpo following platelet transfusion suggests that Tpo kinetics in neonates is similar to adults following transfusion. PF4 was not affected by transfusion. There was not an increase in platelet count following transfusion volume of 15 ml/kg compared to 10 ml/kg.

Effect of blood transfusions on the outcome of very low body weight preterm infants under two different transfusion criteria

BACKGROUND

Multiple packed red blood cell (PRBC) transfusions in very low birth weight (VLBW) prematurity have been suggested to be a risk factor for the development of retinopathy of prematurity (ROP) or for chronic lung disease (CLD). The purpose of this study was to examine the effect of PRBC transfusions on the outcome of VLBW prematurity.

METHODS

In total, between July 2005 and June 2006, 36 VLBW preterm babies were admitted to our neonatal intensive care unit and were randomly allocated to the "restrictive" (n= 19) or "liberal" (n= 17) criteria for PRBC transfusion. Complete blood count (CBC) was examined at admission and 30 days later. Reticulocyte counts, serum iron and ferritin were examined and compared with the clinical outcomes.

RESULTS

Infants in the liberal group received a larger PRBC transfusion volume compared with the restrictive group over 30 days (41.7+/-20.1 vs. 27.2+/-15.9mL, p=0.029). There were no significant differences in the proportion of patients with respiratory distress syndrome, patent ductus arteriosus, severe intraventricular hemorrhage, ROP or CLD between the two groups. The laboratory data, except reticulocyte count, showed no significant difference on day 30. Further analysis of premature babies with and without CLD showed that total transfused blood volume greater than 30mL over 30 days was a risk factor for developing CLD in VLBW infants.

CONCLUSION

Both criteria of PRBC transfusion had similar clinical outcomes, although liberal transfusion resulted in a greater amount of blood transfused and a low reticulocyte count at 30 days of age. We suggest restrictive criteria for minimizing the overall amount of transfusion to less than 30 mL may be a better way of preventing CLD in VLBW infants.

Increased blood plasma concentrations of TGF-beta1 and TGF-beta2 after treatment with intravenous immunoglobulins in childhood autoimmune diseases

Transforming growth factor-beta (TGF-beta), a multifunctional, immunosuppressive cytokine, is shown to be present in substantial amounts in commercially available intravenous immunoglobulin (IVIG) preparations. To assess whether TGF-beta isoforms are changed in the plasma of paediatric patients with childhood autoimmune diseases after IVIG infusion, 17 patients who received over a period of 12 months overall 56 IVIG infusions (Endobulin) were enrolled in a study. High levels of TGF-beta1 (16.95 +/- 8.16 ng/ml) as well as TGF-beta2 (62.71 +/- 9.50 ng/ml) were detected in the used 56 IVIG probes. TGF-beta1 and TGF-beta2 plasma concentrations were measured prior and 120 min after IVIG infusions by specific TGF-beta ELISA. Interestingly, significant increased TGF-beta1 and TGF-beta2 plasma levels were found in patients after treatment with IVIG. This data suggest that a TGF-beta-mediated mechanism of action may accompany other molecular effects of IVIG therapy. The amount of the potent anti-inflammatory TGF-beta isoforms within the IVIG preparations may exert a differentiated view regarding the manifold indications of IVIG therapy.

Vascular endothelial growth factor as marker for tissue hypoxia and transfusion need in anemic infants: a prospective clinical study

OBJECTIVE

Oxygen-carrying capacity of blood is reduced in anemic infants because of low hemoglobin levels. Red blood cell transfusions become necessary if low hematocrit causes tissue hypoxia. No reliable parameters exist for detecting chronic tissue hypoxia. Vascular endothelial growth factor is upregulated by hypoxia; hence, elevated vascular endothelial growth factor levels may be a marker for tissue hypoxia and may indicate the need for red blood cell transfusions.

METHODS

In a prospective study, plasma vascular endothelial growth factor levels were measured in 3 groups of infants suspected of requiring red blood cell transfusions to find a vascular endothelial growth factor cutoff value indicative of tissue hypoxia. The 3 groups were acute anemic (an episode of acute bleeding [hematocrit drop > 5%] per day); chronic anemic (hematocrit drop < 5% per day); and nontransfused (hematocrit drop < 5% per day) but not meeting clinical criteria for a transfusion. Blood was sampled before transfusion and again 48 hours after transfusion if required. Plasma vascular endothelial growth factor and erythropoietin concentrations were measured.

RESULTS

Vascular endothelial growth factor concentrations were lower in acutely anemic compared with chronically anemic infants, whereas erythropoietin levels did not differ between these groups. The vascular endothelial growth factor concentration was <140 pg/mL in all acutely anemic infants, and this was deemed the threshold level indicating sufficient tissue oxygenation in subsequent analysis. We found that 30% of chronically anemic and 43% of nontransfused infants had vascular endothelial growth factor levels of >140 pg/mL. In transfused infants, with elevated vascular endothelial growth factor levels, red blood cell transfusion resulted in lowering of vascular endothelial growth factor concentrations.

CONCLUSIONS

Vascular endothelial growth factor concentrations of >140 pg/mL may indicate insufficient oxygen delivery to tissues and may serve as a marker of the need for transfusion or of tissue hypoxia in other diseases.

The use of blood products in perinatal medicine

Fetal and neonatal medicine is a field with many new procedures and techniques. An increasing number of centres worldwide give intrauterine transfusions, which are considered to be standard-of-care treatment for severe fetal anaemia. The survival of very prematurely born neonates, in particular of a gestational age of <28 weeks, has greatly improved over the last decade but almost all these children need transfusions. Although in many cases such blood transfusions are life saving, randomized, controlled studies investigating appropriate indications, transfusion volume and type of blood product have not been performed. Most of the protocols used are expert based.

How to tackle bleeding and thrombosis in the newborn

Bleeding and its management represent common clinical problems in neonatal intensive care, particularly in pre-term infants. Frank and severe single organ haemorrhage (e.g. pulmonary or gastrointestinal in association with necrotising enterocolitis) is less common, but may require urgent resuscitation and clinical stabilisation. Intracranial bleeding is always potentially of greatest concern because of the neurological consequences, but the pathophysiological mechanism of the most characteristic form, intraventricular haemorrhage, remains incomplete. Minor forms of bleeding are commonly seen in sicker neonates, ranging from blood stained endotracheal secretions to longer than expected oozing from phlebotomy sites, but may be manifestations of disseminated intravascular coagulation. The mainstay of treatment for bleeding in association with abnormalities of coagulation or thrombocytopenia remains blood products, although their role as prophylaxis to prevent bleeding in neonates without clinical signs of haemorrhage is less clear. The overwhelming majority of thromboembolic events in neonates occur in association with arterial or venous catheters, but the clinical features are very variable, including catheter dysfunction and local signs. The optimal treatment strategies including use of anticoagulants remain problematic in the absence of good clinical trials.

Adherence to NICU transfusion guidelines: data from a multihospital healthcare system

OBJECTIVE

We critically reviewed every NICU blood component transfusion (packed erythrocytes, platelets, frozen plasma (FP) and cryoprecipitate) administered during a one-year period. This was done to determine the proportion of transfusions given out of compliance with the Intermountain Healthcare transfusion guidelines, and to look for patterns of non-compliance that could be addressed by quality improvement measures.

STUDY DESIGN

A detailed review was made of every transfusion administered to patients with a date of birth of 1 January 2006 through 31 December 2006, in any of three level III, perinatal-center-associated NICUs within Intermountain Healthcare.

RESULT

During 2006 the three NICUs cared for 1759 neonates. Seventeen percent of these received one or more (median 3) erythrocyte transfusions, 4% received one or more (median 3) platelet transfusions, 6% received one or more (median 1) FP infusions and 2% received cryoprecipitate (median 1 dose). Seventy percent of the erythrocyte transfusions were given in compliance with the guidelines, as were 69% of the platelet transfusions, 65% of the FP transfusions and 94% of the cryoprecipitate administrations. Patients who received large numbers of transfusions were more likely to receive transfusion that violated the guidelines. Forty-five percent of patients who received 1 to 3 transfusions received all transfusions within guidelines. However, only 18% of patients who received 4 to 10 transfusions received all within guidelines. No patient who received >10 transfusions received all within the guidelines. Erythrocyte transfusions given early in the hospital course were likely to be within guidelines; 72% (588/818) in the first 29 days were compliant with guidelines, but compliance fell to 61% (144/237) for transfusions administered after 29 days (P=0.002). About half of the platelet transfusions given early in the hospital course were in violation of guidelines, but after day 9, 83% of platelet transfusions were compliant with guidelines (P=0.000).

CONCLUSION

Opportunities exist in our healthcare system to improve compliance with our transfusion guidelines. Such opportunities are greatest among neonates receiving multiple transfusions, among those receiving erythrocyte transfusions late in their NICU course and among those receiving platelet transfusions early in their NICU course.

Blood and blood component therapy in neonates

Blood component therapy is a very common intervention practiced in newborns; nearly 85% of extremely low birth weight (ELBW) babies get transfusions during their hospital stay. However, there are no set guidelines for transfusion of blood component therapy in newborns. This protocol includes available types of blood components, their methods of preparation, indications and side effects of transfusion, in relation to newborns.

Advances and controversies in neonatal ICU platelet transfusion practice

Some of the platelet transfusions currently given to NICU patients are unnecessary and convey no benefits. Although ordered with good intentions, unnecessary platelet transfusions carry known and unknown risks. Identifying and eliminating any unnecessary platelet transfusions in NICUs would be a step toward better care, lower costs, and more careful preservation of blood component resources. A renewed interest in platelet transfusion studies is needed, if essential data is to be gathered to improve NICU platelet transfusion practice. Retrospective studies can be of value: for instance, seeking associations between bleeding events and platelet counts can suggest the possibility of cause and effect relationships. Such studies might identify approximate platelet count levels that convey high hemorrhagic risk and might help focus future prospective trials. Prospective indirect studies also can be of value, for instance, measuring the template bleeding time and the PFA-100 closure time as a function of platelet count and perhaps as a function of circulating platelet mass, and would provide new information with relevance to platelet transfusion benefits. Such studies might give a better awareness of how low the platelet count can fall before platelet plug formation is impaired. It seems inescapable, however, that new, multicentered, randomized, prospective studies are needed, where NICU patients are assigned different platelet transfusion triggers and then carefully tracked for bleeding events and long-term neurodevelopmental outcomes. Only that type of study is likely to generate the evidence base needed for widespread implementation of improvements in NICU platelet transfusion practice.

A systematic review and survey of the management of unexpected neonatal alloimmune thrombocytopenia

BACKGROUND

Unexpected neonatal alloimmune thrombocytopenia (NAIT) may have devastating consequences and its management is challenging. To design future trials, evidence from the literature and existing best practice need review.

STUDY DESIGN AND METHODS

This study was a cross-sectional survey of neonatal units in Germany and Canada to determine management strategies of NAIT and a systematic search for randomized controlled trials (RCTs).

RESULTS

Management of NAIT differs substantially between countries with regard to platelet (PLT) thresholds for screening, initiation of therapy, and treatment. Seventy-seven percent of Canadian physicians versus 68 percent of German physicians screen preterm and term infants, at a PLT threshold of 30 x 10(9) to 100 x 10(9) per L. In preterm infants, 60 percent of Canadian neonatologists commence treatment at a PLT count of between 30 x 10(9) and 50 x 10(9) per L. In Germany 32 percent of the physicians start treatment at this level and 25 percent use a threshold of between 10 x 10(9) and 20 x 10(9) per L. In term infants, 6 percent of the Canadian physicians and 16 percent of the German physicians use even lower treatment triggers of between 5 x 10(9) and 10 x 10(9) per L. In the presence of bleeding, 61 percent of German physicians await the arrival of antigen-negative PLTs, while 64 percent of Canadian neonatologists prefer intravenous immunoglobulin or random-donor PLTs (81%). Maternal PLTs are utilized by 31 percent of physicians in both countries. No RCTs were identified.

CONCLUSION

In the absence of RCTs, management of unexpected NAIT differs between countries. Clinicians and transfusion services may use the results of our study to develop collaborative protocols, redefine preferred hospitalwide strategies, and design future controlled trials.

Platelet transfusions

Ever since platelet transfusions were shown to reduce mortality from haemorrhage in patients with acute leukaemia in the 1950s, the use of this therapy has steadily grown to become an essential part of the treatment of cancer, haematological malignancies, marrow failure, and haematopoietic stem cell transplantation. Today, more than 1.5 million platelet products are transfused in the USA each year, 2.9 million products in Europe. However, platelet transfusion can transmit infections and trigger serious immune reactions and they can be rendered ineffective by alloimmunisation. There are several types of platelet components and all can be modified to reduce the chances of many of the complications of platelet transfusion. Transfusion practices, including indications for transfusion, dose of platelets transfused, and methods of treating alloimmunised recipients vary between countries, and even within countries. We review commonly used platelet components, product modifications, transfusion practices, and adverse consequences of platelet transfusions.

Haemolytic disease of the newborn

The changing management of haemolytic disease of the newborn is reviewed

Myocardial adaptation to anemia and red blood cell transfusion in premature infants requiring ventilation support in the 1st postnatal week

BACKGROUND

Although transfusion practice in very premature infants is becoming more restrictive, little is known about myocardial adaptation to anemia during the 1st postnatal week.

OBJECTIVES

To determine the central hemodynamic effects of anemia and red blood cell transfusion in very preterm infants undergoing intensive care.

METHODS

Twenty-nine neonates of less than 30 weeks gestational age were treated for respiratory distress syndrome, following a strict protocol. Echocardiographies were performed at the 4th and 6th postnatal days, which corresponded to, respectively, just before and 48 h after an erythrocyte transfusion of 15 ml/kg in the 12 anemic infants.

RESULTS

Anemic infants had increased stroke volume [2.1 (1.8-2.3) vs. 1.5 (1.3-1.6) ml/kg] and left ventricular (LV) output [312 (271-345) vs. 206 (177-240) ml/min/kg]. The relationship of the heart rate-corrected velocity of circumferential fiber shortening to LV end-systolic meridional wall stress indicated a higher contractile state in the anemic infants, with a higher y-intercept (p = 0.03) and a steeper slope (p = 0.05) of the regression line than in the nonanemic patients. Posttransfusion, the stroke volume, LV output, shortening fraction, and contractile state decreased to the values observed in the nonanemic infants.

CONCLUSIONS

Myocardial contractility was a major component of the circulatory adjustments in the anemic premature infants requiring ventilation support in the early neonatal period. Changes in LV performance associated with anemia were reversed by transfusion with no detrimental effect on right ventricular function, LV preload or the respiratory status of these patients.