#OA4-AM25-ST-08 - Reduced Platelet Transfusion Dosing Safely Limits Infant Platelet Exposure and Decreases Costs

Infants with low platelet counts often receive prophylactic transfusions of donated adult platelets to prevent bleeding, but current transfusion practices paradoxically increase bleeding, neurocognitive impairment, respiratory complications, and death in preterm neonates. This is likely due to differences in adult vs neonatal platelets. In prior studies, 10 ml/kg platelet transfusions effectively raised platelet counts and prevented bleeding in neonates, yet most transfusions were given at 15-20 ml/kg in our neonatal intensive care unit (NICU). Limiting adult platelet exposure should thus improve neonatal outcomes and conserve limited supplies of donated platelets.

Study

Design/Methods:

We used quality improvement methods to identify and address key issues. We excluded infants with procedures within 12 h, active bleeding, who were on anticoagulation, or ECMO. The primary outcome measure was 10 ml/kg platelet transfusions orders. Balancing measures were 1) repeat platelet transfusions within 36 hours and 2) frequency of major bleeding within 72 h of transfusion. We created charts with QI Macros (v 2024.10). We performed a cost savings analysis based on average platelet unit size (200-360 ml/unit) and estimated cost (~$700/unit).

Results/Findings:

We identified key practice drivers as 1) preconceptions about platelet safety, 2) cultural unit standards, and 3) default transfusion order sets. We created platelet dosing guidelines and changed practices via 3 plan-do-study-act (PDSA) cycles, which targeted 1) staff education, 2) reminder screensavers and cards posted on NICU computers; and 3) clinical decision support via new order sets.

We reviewed 240 transfusions in 66 patients over 3 yrs. Prior to the study, 18% of transfusions were ordered at 10 ml/kg (most were 15-20 ml/kg). After the study, 100% of prophylactic transfusions were ordered at 10 mL/kg (Figure), with no changes in repeat transfusions or bleeding complications. 
Coupled with reduced transfusion thresholds (Gilmore et al, Transfusion 2024), platelet transfusions in our NICU decreased by 50% during our study (1.5 transfusions per 100 patient-days at study initiation vs 0.7 transfusions per 100 patient-days at study completion). Over the same period, the volume of platelets transfused decreased by 63% (64.5 vs 23.6 mL per 100 patient-days). Monthly transfused platelet volumes decreased from the pre-intervention to sustain periods (2269±334 mL versus 857±181 mL, p< 0.001), conserving limited platelet resources and saving $2746-$4942 per month in stored platelets.

Conclusions:

We standardized 10mL/kg prophylactic platelet transfusion dosing in our NICU. This practice change will optimize safety and efficacy of neonatal platelet transfusions, while conserving limited donated platelet supplies and generating substantial cost savings.