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Platelet Transfusion Practices for Critically Ill Children: A 28-Day Point-Prevalence Study in Three European
Laura Butragueño-Laiseca1,2,3,4, Avishay Sarfatti5, Samiran Ray6
1Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Insights
Platelet transfusions are common in critically ill children, primarily for low platelet counts, not active bleeding. Higher transfusion rates correlate with increased mortality, highlighting the need for optimized transfusion strategies.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology
- Transfusion Medicine
Background:
- Platelet transfusions are a cornerstone therapy for critically ill children.
- Understanding current transfusion practices, indications, and outcomes is crucial for optimizing patient care.
- Variability in transfusion thresholds and triggers necessitates further investigation.
Purpose of the Study:
- To determine the prevalence, indications, and thresholds for platelet transfusions in European pediatric intensive care units (PICUs).
- To analyze the outcomes, including mortality, associated with platelet transfusions in critically ill children.
- To evaluate the effectiveness of current transfusion practices and identify areas for improvement.
Main Methods:
- International 4-week point-prevalence study conducted in 2023 across 44 PICUs in Spain, the UK, and Italy.
- Included 2713 pediatric patients (1 month to 17 years) receiving platelet transfusions.
- Data collected on transfusion indications, pre- and post-transfusion platelet counts, and 28-day mortality.
Main Results:
- 4.1% of patients received platelet transfusions, with low platelet count (54%) and prophylactic indications (83%) being primary reasons.
- Median pretransfusion platelet count was 36×10^9 cells/L, varying significantly by diagnosis.
- 28-day PICU mortality was 21.8%, with higher transfusion rates and doses associated with increased mortality.
Conclusions:
- Platelet transfusions are frequently administered for low platelet counts, often prophylactically, with considerable variability in practice.
- Current transfusion practices may exceed recommended thresholds, and outcomes suggest an association with mortality.
- Further pediatric trials are needed to establish optimal platelet transfusion thresholds and triggers in critically ill children.
Objectives:
To study the prevalence, indications, thresholds, and outcomes of platelet transfusions in critically ill children in three European countries.
Design:
International 4-week point-prevalence study in 2023.
Setting:
Forty-four PICUs across Spain, the United Kingdom, and Italy.
Patients:
PICU patients of 1 month to 17 years old receiving platelet transfusions.
Interventions:
None.
Measurements And Main Results:
During four prespecified 7-day blocks, 110 of 2713 (4.1% [95% CI, 3.4-4.9%]) patients received at least one platelet transfusion, accounting for 253 transfusions. The primary indication was a low platelet count (PC) (54% [95% CI, 48-60%]), and 83% (95% CI, 77.7-87.4%) were prophylactic indications. Active bleeding was the main reason for transfusion in only 17% of cases (12.6-22.2). Median pretransfusion PC was 36 × 10 9 cells/L. PC differed significantly across diagnostic subgroups and indications. It was higher in postsurgery cardiac (83 × 10 9 cells/L) and nonsurgery cardiac patients (61 × 10 9 cells/L) and lower in septic shock (24 × 10 9 cells/L) and hemato-oncological conditions (23 × 10 9 cells/L). Posttransfusion (2 hr) PC increment was 42 × 10 9 /L, but by 12-24 hours it decreased to 13 × 10 9 /L, regardless of patient diagnosis or reason for transfusion. Viscoelastic testing was performed in only seven events (2.8%). The 28-day PICU mortality was 21.8% (95% CI, 14.6-30.4%). The number and total dose of transfusions were associated with mortality, even after adjusting for the Pediatric Index of Mortality III score.
Conclusions:
In 44 European PICUs in 28 days during 2023, 4% of admitted patients received platelet transfusions. PC was the primary reason for transfusion, with substantial variability between subgroups and indications. There were a high number of prophylactic transfusions, and exceeding the recommended restrictive threshold was common. The observed change in the patients' PC is not related to the reason for the platelet transfusion or the patient's diagnosis. Viscoelastic testing is still rarely performed. These results support the need for pediatric trials to define safe and effective platelet thresholds and to evaluate the role of other transfusion triggers in critically ill children.
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