Abstract
To evaluate the usability of platelet mass index (PMI) thresholds to assess the repeated platelet transfusion requirements in neonates who have received transfusion within the previous six days. This is a retrospective cross-sectional study conducted with neonates who received prophylactic platelet transfusion. The PMI was calculated as platelet count (× 1000/mm3) × mean platelet volume (MPV) (fL). Platelet transfusions were divided into two groups as first (Group 1) and repeated transfusions (Group 2). The increment and percentage of increment in platelet counts, MPV and PMI after transfusion were compared between the two groups. The amounts of changes were calculated as: (Post-transfusion) − (Pre-transfusion values). The percentages of changes were calculated as: ([Post-transfusion − Pre-transfusion values]/Pre-tansfusion values) × 100. Eighty three platelet transfusions were analyzed in 28 neonates. The median gestational age and birth weight were 34.5 (26–37) weeks, and 2225 (752.5–2937.5) grams, respectively. There were 20 (24.1%) transfusions in Group 1, and 63 (75.9%) transfusions in Group 2. There were no differences in the amounts of changes in platelet counts, MPV and PMI between the groups (p > 0.05). When the percentages of changes were analyzed, it was found that the platelet counts and PMI in Group 1 increased to a greater extent compared to Group 2 (p = 0.026, p = 0.039, respectively), but no significant difference was found in MPV between the groups (p = 0.081). The lower percentage of change in PMI in Group 2 was associated with the lower percentage of change in platelet counts. Being transfused with adult platelets did not affect platelet volume of the neonates. Therefore, PMI thresholds can be used in neonates with a history of platelet transfusion.
Keywords: Neonate, Platelet mass index, Platelet transfusion, Thrombocytopenia
Introduction
Thrombocytopenia (a platelet count below 150,000/mm3) affects approximately one-fourth of neonates in neonatal intensive care units (NICUs), and the incidence increases with decreasing gestational age, with approximately 70% of very low birth weight neonates experiencing thrombocytopenia [1–5]. Although there is insufficient evidence to show a causal relationship between platelet counts and bleeding risk in neonates, clinical practice involves the use of prophylactic platelet transfusions in hospitalized neonates [6, 7]. Platelet transfusion is associated with increased mortality and morbidities such as severe intraventricular hemorrhage, necrotizing enterocolitis, retinopathy of prematurity and acute kidney injury in preterm infants [4, 8, 9]. Therefore, the benefit of prophylactic platelet transfusions in neonates is debated, and the usage of a restrictive neonatal platelet transfusion guideline is supported to reduce potentially harmful platelet transfusions in NICUs [7, 8, 10–12].
The mechanism underlying the undesirable adverse effects of higher platelet transfusion threshold is not known, but it might be related to the fact that transfusing adult platelets into a neonate causes a developmental mismatch with an increased risk for hyperreactivity, hemostatic imbalance and pro-inflammatory effect [7, 13]. The number and structure of platelets in healthy neonates are similar to those of adults, but there are significant functional differences between neonatal and adult platelets [12]. Also, neonatal megakaryocytes are smaller and produce fewer platelets than adult megakaryocytes [12, 13]. As neonates have the longest potential lifespan living with adverse events associated with platelet transfusion [14], it is advisable to keep in mind the differences between the neonatal and adult hemostatic systems while deciding platelet transfusion [15].
Assuming normal function of platelets and endothelium, the efficacy of platelet plug formation is influenced by both the number of platelets and platelet mass, and larger platelets are known to function better to form an effective platelet plug [16]. The use of platelet mass index (PMI) reference values rather than platelet count has been reported to reduce the frequency of prophylactic platelet transfusion, and the recommendation for transfusion based on PMI is as follows; PMI is < 800 in pre/postoperative patients, < 400 in unstable patients, and < 160 in stable patients [17–21]. In the studies evaluating the effects of using PMI thresholds for neonatal platelet transfusions, it was not investigated whether neonates were transfused with platelets for the first time or repeatedly [17–20]. The differences in the hemostatic system between neonates and adults made us wonder if it would be appropriate to use PMI thresholds for neonates who have had repeated platelet transfusions, as platelet mass would change due to previous transfusions with larger adult platelets [12, 13, 15]. In our study, we aimed to evaluate the usability of PMI thresholds for repeated platelet transfusion requirements in neonates who received platelet transfusion within previous six days.
Materials and Methods
This was a retrospective cross-sectional study conducted at a Training and Research Hospital. Ethics Committee approval was obtained for the study from the University Clinical Research Ethics Committee (date: 24.05.2021, number: 21.10.22). The neonates, who were admitted to our NICU between February 2020 and February 2021, and received prophylactic platelet transfusion, were included in the study. The neonates in whom the complete blood count device could not detect the mean platelet volumes (MPVs), whose complete blood counts were not checked both before and after the platelet transfusion, and the neonates who were transfused more than six days ago and on anti-platelet drugs, and the ones who were transfused due to active bleeding, were excluded from the study.
The decision for platelet transfusion was mainly made according to our national transfusion guideline [5]. Also, the neonates, whose platelet counts tended to decrease rapidly to a level of < 100,000/mm3 while they were hemodynamically unstable, were transfused in line with the recommendations of a consultant neonatologist. All transfused platelet suspensions were random, ABO and Rh-compatible, leukoreduced and irradiated. The platelet suspensions were in the form of pooled platelet suspensions separated from donors’ whole blood with a maximum shelf life of five days. A whole blood unit, stored in conditions validated to maintain a temperature between + 20 °C and + 24 °C for up to 24 h, was centrifuged so that the platelets were primarily sedimented to the buffy coat layer together with the leucocytes. The buffy coat was separated and further processed so that, four blood group-compatible buffy coats were pooled in a sterile manner (Macopharma maco-connect) and re-suspended with plasma. After careful mixing, the buffy coat pool was centrifuged (soft-spin) so that the platelets remained in the supernatant, but the red cells and leucocytes were sedimented to the bottom of the bag. The platelet-containing supernatant was immediately filtered (Thromboflex TXP filter /Macopharma) and transferred into an approved platelet storage bag using a closed system. The pooled platelets were then irradiated with 25 Gray by the Biobeam GM2000 blood irradiator. We used pooled platelet suspensions obtained from four donors, as we had difficulty in supplying pediatric blood bags, and a unit of platelet suspension was prepared as 250 ml (200–300 ml) on average. Platelet transfusions were performed at a dose of 15–20 mL/kg in a one-hour period. Vital signs were closely monitored before, during, and after transfusion. The platelet count was measured in the following 24 h after transfusion to check the efficacy of the transfusion [5]. Platelet counts and MPVs were determined using the Sysmex XN-1500 device, and PMI was calculated as platelet count (× 1000/mm3) × MPV (fL).
There was no blood bank in the study center, and all blood products were obtained from another city’s blood bank 160 km from our hospital, and a platelet unit could not be dedicated to a single patient to minimize donor exposure. Platelet transfusions were divided into two groups as first platelet transfusions (Group 1) and repeated platelet transfusions (Group 2). Transfusions given to newborns who received platelet transfusion for the first time in their lives constituted Group 1 transfusions. All transfusions in Group 2 were the ones performed within six days of the previous platelet transfusion to evaluate the effects of adult thrombocytes on PMI values in neonates, as the half-life of thrombocytes was considered six days. The amounts and percentages of changes in platelet counts, MPV and PMI values were compared between the two groups. The amounts of changes were calculated as: (Post-transfusion values) − (Pre-transfusion values). The percentages of changes were calculated as: ([Post-transfusion values − Pre-transfusion values]/Pre-tansfusion values) × 100.
The perinatal history, demographic findings, blood culture results, transfontanel ultrasonography reports, the etiology of thrombocytopenia and postnatal day of platelet transfusion were recorded. Transfontanel ultrasonography was performed for all patients before and after platelet transfusion. Sepsis was classified as suspected or confirmed sepsis. Suspected sepsis was considered if the clinical and laboratory findings were consistent with sepsis, but blood culture was negative, and confirmed sepsis was considered in the presence of accompanying positive blood culture in addition to sepsis findings. Presence of at least two of the following criteria was considered sepsis: fever or hypothermia, tachypnea or apnea, tachycardia and abnormal white blood cells or increase in band/total neutrophils [22].
Statistical Analyzes
The Statistical Package for Social Sciences version 21.0 (SPSS Inc., Chicago, IL, USA) was used for statistical analyzes. The data were assessed for normality using visual and analytic methods. Continuous data were tested for normality with the Shapiro Wilk and non-normally distributed variables were expressed as medians (25.-75 quartile, 25–75.QR). Qualitative variables were expressed as percentages and frequencies. Differences between two independent groups were tested using the Mann Whitney U test. A p value of < 0.05 was considered statistically significant.
Results
Eighty three platelet transfusions of 28 neonates were analyzed. The median gestational age and birth weight values of the neonates were found to be 34.5 (26–37) weeks, and 2225 (752.5–2937.5) grams, respectively. During the transfusion, the median weight of the neonates was found to be 2450 (740–3100) grams. We used approximately 19.5% of the total volume of platelet suspensions and 80.5% of the volume of the platelet suspensions was wasted. The most common cause of thrombocytopenia was sepsis (n, %: 21, 75), and most of the patients with sepsis had confirmed sepsis (n, %: 17, 81). Twenty (24.1%) of the transfusions were first transfusions (Group 1), and 63 (75.9%) were repeated transfusions (Group 2). The transfusions of six patients were included in both Group 1 (n = 6) and Group 2 (n = 20). The presence of sepsis did not make any difference in the amounts and in the percentages of changes in platelet counts, MPV and PMI values between the two groups (p > 0.05). The median postnatal day of platelet transfusion was 35 (18–61) days for all transfusions. The demographic and clinical characteristics of the study population are shown in Table 1.
Table 1.
Demographic and clinical characteristics of the neonates transfused with platelets (n = 28)
| Male babies, n (%) | 15 (53.6) |
| Cesarean delivery, n (%) | 17 (60.7) |
| Gestational ages, weeks (25–75. QR) | 34.5 (26–37) |
| Birth weights, grams (25–75. QR) | 2225 (752.5–2937.5) |
| Perinatal history, n (%) | |
| Preeclampsia | 1 (3.6) |
| Chorioamnionitis | 4 (14.2) |
| Premature rupture of membrane | 1 (3.6) |
| Gestational diabetes mellitus | 0 (0) |
| Causes of thrombocytopenia, n (%) | |
| Sepsis | 21 (75) |
| Unknown | 7 (25) |
| Blood culture results, n (%) | |
| Culture negative | 11 (39.3) |
| Gram ( +) | 7 (25) |
| Gram ( −) | 10 (35.7) |
| Death, n (%) | 16 (57.1%) |
| Total number of platelet transfusion, n | 83 |
| First/recurrent transfusion, n (%)/ n (%) | 20 (24.1)/ 63 (75.9) |
| Postnatal day of platelet transfusion, median (25–75. QR) | 35 (18–61) |
QR Quartile
The postnatal day of platelet transfusion was significantly earlier in Group 1 compared to Group 2 (p < 0.001). There were no statistically significant differences between the shelf life of the units transfused, pre-transfusion platelet counts, MPV and PMI values between the two groups (p = 0.093, 0.087, p = 0.301, p = 0.168, respectively) (Table 2). There were no statistically significant differences in the amounts of changes in platelet counts, MPV and PMI values between the groups (p = 0.051, p = 0.079, p = 0.074, respectively) (Table 3). When the percentages of changes in platelet counts, MPV and PMI were analyzed, it was found that the platelet counts and PMI value in Group 1 increased to a greater extent compared to Group 2 after transfusion (p = 0.026, p = 0.039, respectively), and no significant difference was found between the percentage of change in MPV values between the two groups (p = 0.081) (Table 4).
Table 2.
Comparison of postnatal days of platelet transfusion, and pre-transfusion platelet counts, mean platelet volumes and platelet mass index between the two groups
| Categories | First platelet transfusion group Group 1 (n = 20) |
Repeated platelet transfusion group Group 2 (n = 63) |
p* |
|---|---|---|---|
| Postnatal day of platelet transfusion, median (25–75. QR) | 9.5 (4.25–30) | 44 (29–64) | < 0.001 |
| Shelf life of the transfused platelets, median (25–75. QR) | 2 (2–2) | 2 (1–2) | 0.093 |
| Platelet count (× 1000/mm3), median (25–75. QR) | 32.5 (20.45–45) | 43 (24–56) | 0.087 |
| MPV (fL), median (25–75. QR) | 10.3 (8.25–11.7) | 11 (10–11.6) | 0.301 |
| PMI (fL/nL), median (25–75. QR) | 296.1 (164.9–596.8) | 458.8 (264–627) | 0.168 |
MPV mean platelet volume, PMI platelet mass index, QR Quartile
*Mann Whitney U test
Table 3.
Comparison of the amounts of changes in platelet counts, mean platelet volumes and platelet mass index between the two groups
| Categories (Post–pre transfusion values) | First platelet transfusion group Group 1 (n = 20) |
Repeated platelet transfusion group Group 2 (n = 63) |
p* |
|---|---|---|---|
| Platelet count (× 1000/mm3), median (25–75. QR) | 32 (12–50) | 12 (0–36) | 0.051 |
| MPV (fL), median (25–75. QR) | 0.25 [(− 0.3)1] | 0 [(− 0.5)-0.1] | 0.079 |
| PMI (fL/nL), median (25–75. QR) | 293.9 (109.3–453.8) | 129.5 (0–339.9) | 0.074 |
MPV mean platelet volume, PMI platelet mass index, QR Quartile
*Mann Whitney U test
Table 4.
Comparison of the percentages of changes in platelet counts, mean platelet volumes and platelet mass index between the two groups
| Categories ([Post- Pre-transfusion values]/Pre-tansfusion values) × 100 |
First platelet transfusion group Group 1 (n = 20) |
Repeated platelet transfusion group Group 2 (n = 63) |
p* |
|---|---|---|---|
| Platelet count (× 1000/mm3), median (25–75. QR) | 95.7% (33.7–221.4) | 30.8% (0–108.7) | 0.026 |
| MPV (fL), median (25–75. QR) | 2.9% [(− 2,7)-14.4] | 0% [(− 4.3)-0.86] | 0.081 |
| PMI (fL/nL), median (25–75. QR) | 77.2% (23.5–297.3) |
31.4% (0–89.02) |
0.039 |
MPV mean platelet volume, PMI platelet mass index, QR Quartile
*Mann Whitney U test
Discussion
In this study, we evaluated the usability of PMI thresholds to assess the repeated platelet transfusion requirements in neonates and we found that the percentage of change in PMI was higher in the “first transfusion” group compared to the “repeated transfusion” group. As PMI has two determinants including platelet counts and MPV, and the difference in percentage of MPV was similar between the groups, we concluded that the difference in percentage of PMI between the groups was a result of the difference in the percentage of platelet counts rather than the platelet volume. Also, the pre-transfusion values and amounts of changes in platelet counts, MPV and PMI were similar between the groups. The fact that the lower increament in the percentages of changes in platelet counts and thus PMI in the repeated transfusion group than in the first transfusion group might be due to the patient characteristics of the group. Newborns in the repeated transfusion group might have thrombocyte refractoriness, as they might be sicker and have alloimmunization due to repeated transfusions. Although there are known differences between neonatal and adult platelets [12, 13], transfusion of adult platelets to neonates did not seem to affect the platelet size, measured as MPV, and platelet mass of the neonates. Therefore, it could be said that PMI thresholds could be used to assess the repeated platelet transfusion requirements in neonates if there is a chance to reduce the number of platelet transfusions by using PMI thresholds.
The most appropriate platelet transfusion thresholds are still unknown, and the transfusion quidelines change from country to country [2, 14, 15]. Unfortunately, a large proportion of neonatal platelet transfusions are prophylactically administered at thresholds greater than supported by the evidence-based transfusion quidelines, and it has been suggested that there is a need for extensive educational changes and system changes to align platelet transfusion practice with guideline recommendations [25, 26]. Although the results of the studies, that showed platelet transfusions were associated with increased neonatal mortality and morbidity, may be confounded as sicker infants are often the ones to receive a higher number of transfusions, both the benefits and possible hazards of platelet transfusion should be considered while deciding transfusion [4, 7–9]. As the main goal of neonatologists is to keep infants alive and subsequently to reduce morbidity, every effort should be made to achieve those goals.
To our knowledge, this is the first study evaluating the usability of PMI values for repeated platelet transfusions in the neonatal period. The results of the studies evaluating the use of PMI based transfusion criteria in neonates are conflicting [17–20, 23, 24]. In some studies, it was shown that using PMI based transfusion criteria in neonates reduced the number of platelet transfusions [17–20]. On the other hand, other studies found that the use of PMI thresholds could not reduce the number of transfusions [23, 24]. The results of those studies at least showed that the use of PMI thresholds did not result in increased bleeding rates [17–20, 23, 24]. Therefore, the usability of PMI thresholds is still a subject of research, and more studies are needed to use PMI thresholds rather than or in addition to platelet count. In addition, although it was not the aim of this study, it was disappointing to see that 80.5% of the volume of platelet suspensions was wasted since we could not provide pediatric blood bags, and we also wanted to draw attention to this issue.
Our study has some methodological limitations. Firstly, the retrospective design of the study did not allow us to assess the compliance with predetermined transfusion thresholds, as the clinical situation to make transfusion decision was not known exactly. Secondly, the power of the study was low (power of the percentage of change in PMI = 0.72) due to the small sample size. Therefore, it could be recommended to conduct future studies with larger number of transfusions. Thirdly, we did not evaluate the possible confounding factors (such as severity of patients clinical condition, presence of alloimmunization, platelet refractoriness, splenomegaly, etc.) to do matching between groups. Fourthly, we did not study corrected count increment and percent platelet recovery to either guide transfusions or find out the efficiency of transfusions. Finally, the patients with pseudothrombocytopenia could not be determined, as thrombocytopenia was not confirmed with peripheral blood smear.
Conclusion
In conclusion, the percentages of changes in platelet counts and PMI were greater in the first transfusion group than in the repeated transfusion group. On the other hand, the percentage of change in platelet size, measured as MPV, was similar between groups. It could be said that the difference in the percentage of change in PMI between the groups was due to the difference in the percentage of change in platelet counts rather than the percentage of change in platelet volume. The PMI of neonates was not found to be affected by being transfused with adults platelets within previous six days, and it is feasible to use PMI thresholds for repeated platelet transfusions in the neonatal period to prevent hazardous effects of unnecessary transfusions. Prospective studies are still needed to find out new platelet function assays to identify neonates at risk of bleeding, best platelet transfusion thresholds, optimal platelet dosing, and long-term outcomes of transfusion in neonates.
Authors’ Contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AOG, SG and MEA. The first draft of the manuscript was written by AOG, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
No funds, grants, or other support was received.
Availability of Data and Material
If editors or referees request, we can share our patient data.
Declarations
Conflict of interest
The authors have no relevant financial or non-financial interests to disclose.
Consent for Publication
The Research Ethics Committee approved our request to publish anonymized data for this study.
Consent to Participate
Due to the retrospective nature of the study, no patient consent was required for this study.
Ethics Approval
This study was performed in line with the principles of the Declaration of Helsinki. The study protocol was approved by Harran University Clinical Research Ethics Committee (date: 24.05.2021, number: 21.10.22).
Footnotes
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Contributor Information
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Data Availability Statement
If editors or referees request, we can share our patient data.