Standardized Prophylactic Platelet Transfusion Dose for Infants Decreases Platelet Exposure without Increasing Bleeding or Transfusion Frequency

Background

Thrombocytopenia (<150,000 platelets/ul blood) is frequent among neonatal intensive care unit (NICU) patients, including 70% of extremely low birth weight infants. Severe thrombocytopenia is often treated with prophylactic transfusions of donated adult platelets in an effort to prevent bleeding. However, current transfusion practices actually increase bleeding, neurocognitive impairment, respiratory complications, and death in preterm neonates. This is likely due to physiologic differences in adult vs neonatal platelets. Thus, reducing adult platelet exposure will optimize neonatal outcomes and also conserve limited donated platelet resources. Prior clinical studies have demonstrated that 10mL/kg platelet transfusions can effectively treat thrombocytopenia.

Objective

We aimed to standardize 10 ml/kg prophylactic platelet transfusions in our quaternary neonatal intensive care unit (NICU) to >80% of ordered platelet transfusions in non-bleeding patients.

Methods

We identified 1) preconceptions about platelet safety, 2) default order sets with our electronic ordering system, and 3) cultural standards related to transfusion dosing as key drivers of current practices. Infants with procedures/surgeries within 12 hours, on anticoagulation, bleeding, or on ECMO were excluded. The primary outcome measure was compliant 10 ml/kg platelet transfusions orders. Our balancing measure were 1) repeat platelet transfusions within 36 hours and 2) frequency of major bleeding within 72 h of transfusion.

Results

We created a graphic dashboard based on our electronic medical record to monitor platelet ordering in real time. To define baseline practices, we tracked transfusions in the year prior to initiating our study. Our baseline compliance for 10 ml/kg platelet transfusion orders was 14%. Instead, most prophylactic transfusions were dosed at 15-20 ml/kg.

Our first plan-do-study-act (PDSA) cycle targeted education through messaging at staff meetings, on NICU-wide computer screensavers, and laminated reminder cards posted at unit workstations where platelet transfusions were ordered. A second PDSA cycle reinforced platelet dosing guidelines among clinicians through newsletters and staff huddle discussions. A third PDSA cycle targeted clinical decision support within the medical record that eased ordering through defaults to recommended dosing. After consensus agreement from neonatology, cardiology, emergency medicine, oncology, and pediatric intensive care unit clinicians, we implemented electronic order set changes hospital-wide to most effectively spread practice change related to neonatal platelet transfusion dosing across all hospital units.

We monitored 165 transfusions among 55 neonates (2022-2024). Following our PDSA cycle interventions, we achieved >80% dosing compliance, noting special cause variation with sustained process change that resulted in a center line shift from 14% to 88% ‘compliant’ (10 ml/kg) transfusions. There was no change in the rate of subsequent platelet transfusions within 36 hours, nor an increase in major bleeding complications within 72 hours post-transfusion. Coupled with more restrictive platelet transfusion thresholds across our network, as described in network-wide transfusion guidelines (Gilmore et al, Transfusion 2024), platelet transfusions dropped by 44% in the first 6 months after electronic order changes (p<0.05 by two tailed t test).

Conclusion

A standardized prophylactic platelet transfusion dose of 10mL/kg was established through hospital-wide collaborative efforts. We used clinician education and electronic medical record technologies to improve platelet transfusion practices within our NICU, reducing platelet exposures that have been linked with adverse outcomes in preterm neonates. Standardized 10ml/kg platelet transfusion dosing will optimize safety and efficacy of neonatal platelet transfusions and conserve limited donated platelet supplies in line with current literature.