weekly_question 2/3/2025

[Admin]

A two day old former 30 week premature 1.2 kg infant underwent resection and ileostomy for ileal atresia. Two hours after surgery, the HR is 140 and mean arterial pressure is 30-32 mm Hg. He is intubated on pressure support, FiO2 21% with oxygen saturation of 98%. Urine output is adequate. Hgb is 11g/dL and platelet count is 45,000/microliter. INR is 1.6 and PTT is 40 sec. There is no evidence of ongoing bleeding. The infant should receive

a no blood products

b red blood cells

c platelets

d plasma

e platelets and plasma

[Admin]

Correct answer
a no blood products

Transfusion guidelines in VLBW (< 1500 g) neonates continue to undergo modifications. Guidelines have taken into consideration the age and weight of the patient, hemodynamic status, and need for respiratory assistance. A recent systematic metaanalysis and review of guidelines in this age group using PRISMA methodology included six randomized controlled trials, with 3,483 infants. [1] The authors concluded that restrictive transfusion does not increase the risk of all-cause mortality (RR, 0.99; 95% CI, 0.84 to 1.17; I2 = 0%; high-quality evidence), and does not increase the composite outcome of death or neurodevelopmental impairment (RR, 1.01, 95% CI, 0.93–1.09; I2 = 7%; high-quality evidence) or other serious adverse events.

Unfortunately, each of the six articles had different restrictive or liberal thresholds for hemoglobin ranging from < 7g/dL to 10g/dL in the restrictive category.

The neonatal hemostatic system is different from that of adults. [2]Preterm neonates have average platelet counts close to adult levels at birth but platelets do not reach full function until day of life 10-14. Compensatory factors that help mitigate platelet hyporeactivity in newborns include increased hematocrit, increased von Willebrand factor, shorter bleeding times, and shorter platelet function tests. All these factors suggest that primary hemostasis in newborns is enhanced, despite a relatively low platelet count. Therefore, platelet transfusions should be administered to thrombocytopenic newborns with active bleeding. Non-bleeding preterm neonates who received prophylactic platelets transfusions for platelet count < 50,000 had significantly higher bleeding and mortality compared to neonates transfused only for platelet count < 25,000.

Neonates have reduced levels of coagulation factors, particularly vitamin K dependent factors. Factor VIII and Factor XIII are the same as adults and von Willebrand factor is elevated. Newborns have low levels of antithrombin II, protein C, and protein S. Therefore, PT and PTT are longer in preterm and term neonates (preterm>term) and decrease in the first few days after birth. Thrombin generation is faster in neonates than in adults. Tests of whole blood hemostasis (TEG, ROTEM) show faster initiation and propagation of coagulation in neonates compared to adults. Interestingly, prophylactic FFP transfusions given to preterm infants or in response to prolonged PT or PTT do not decrease the incidence or severity of IVH.

While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelet transfusions.

[Abd El wahed]

A

[Bilal]

A

[Mohamed ahmed Abd elsalam]

A

[Jehangir.khan]

A.

[Monyei oluchi]

A

[Massada]

A

[Admin]

Correct answer
a no blood products

Transfusion guidelines in VLBW (< 1500 g) neonates continue to undergo modifications. Guidelines have taken into consideration the age and weight of the patient, hemodynamic status, and need for respiratory assistance. A recent systematic metaanalysis and review of guidelines in this age group using PRISMA methodology included six randomized controlled trials, with 3,483 infants. [1] The authors concluded that restrictive transfusion does not increase the risk of all-cause mortality (RR, 0.99; 95% CI, 0.84 to 1.17; I2 = 0%; high-quality evidence), and does not increase the composite outcome of death or neurodevelopmental impairment (RR, 1.01, 95% CI, 0.93–1.09; I2 = 7%; high-quality evidence) or other serious adverse events.

Unfortunately, each of the six articles had different restrictive or liberal thresholds for hemoglobin ranging from < 7g/dL to 10g/dL in the restrictive category.

The neonatal hemostatic system is different from that of adults. [2]Preterm neonates have average platelet counts close to adult levels at birth but platelets do not reach full function until day of life 10-14. Compensatory factors that help mitigate platelet hyporeactivity in newborns include increased hematocrit, increased von Willebrand factor, shorter bleeding times, and shorter platelet function tests. All these factors suggest that primary hemostasis in newborns is enhanced, despite a relatively low platelet count. Therefore, platelet transfusions should be administered to thrombocytopenic newborns with active bleeding. Non-bleeding preterm neonates who received prophylactic platelets transfusions for platelet count < 50,000 had significantly higher bleeding and mortality compared to neonates transfused only for platelet count < 25,000.

Neonates have reduced levels of coagulation factors, particularly vitamin K dependent factors. Factor VIII and Factor XIII are the same as adults and von Willebrand factor is elevated. Newborns have low levels of antithrombin II, protein C, and protein S. Therefore, PT and PTT are longer in preterm and term neonates (preterm>term) and decrease in the first few days after birth. Thrombin generation is faster in neonates than in adults. Tests of whole blood hemostasis (TEG, ROTEM) show faster initiation and propagation of coagulation in neonates compared to adults. Interestingly, prophylactic FFP transfusions given to preterm infants or in response to prolonged PT or PTT do not decrease the incidence or severity of IVH.

While life-saving in the presence of active major bleeding, the administration of platelets and/or FFP to non-bleeding neonates based on laboratory tests has not only failed to decrease bleeding, but has been associated with increased neonatal morbidity and mortality in the case of platelet transfusions.