Plasma transfusions in neonatal intensive care units: a prospective observational study

Abstract

Objective: Despite lack of evidence supporting efficacy, prophylactic fresh frozen plasma and Octaplas transfusions may be administered to very preterm infants to reduce bleeding risk. International variation in plasma transfusion practices in neonatal intensive care units (NICUs) is poorly understood, therefore, we aimed to describe neonatal plasma transfusion practice in Europe.

Design: Prospective observational study.

Setting: 64 NICUs in 22 European countries, with a 6-week study period per centre between September 2022 and August 2023.

Patients: Preterm infants born below 32 weeks of gestational age.

Interventions: Admission to the NICU.

Main outcome measures: Plasma transfusion prevalence, cumulative incidence, indications, transfusion volumes and infusion rates and adverse effects.

Results: A total of 92 of 1143 infants included (8.0%) received plasma during the study period, collectively receiving 177 transfusions. Overall prevalence was 0.3 plasma transfusion days per 100 admission days, and rates varied substantially across Europe. By day 28 of life, 13.5% (95% CI 10.0% to 16.9%) of infants received at least one plasma transfusion, accounted for competing risks of death or discharge. Transfusions were given for a broad range of indications, including active bleeding (29.4%), abnormal coagulation screen results (23.7%) and volume replacement/hypotension (21.5%). Transfusion volumes and infusion rates varied significantly; the most common volume was 15 mL/kg (range: 5-30 mL/kg) and the most common duration was 2 hours (range: 30 min to 6 hours).

Conclusions: We found wide variation in plasma transfusion practices in Europe, highlighting the need for evidence to inform neonatologists in daily practice and guidelines, in particular for non-bleeding indications.

Trial registration number: ISRCTN17267090.

Keywords: Epidemiology; Intensive Care Units, Neonatal; Neonatology.

Figure 1. Overall plasma transfusion prevalence. Observed prevalences were calculated using random effects Poisson models to pool the transfusion prevalence per centre into country subgroup estimates and subsequently to derive the overall estimate. Upper limit CIs of Germany and Romania are outside axis limits. Expected prevalence as predicted based on patient-mix using a logistic regression model which included the following variables: sex, gestational age at birth, birth weight, congenital malformations, major bleeding, necrotising enterocolitis (NEC), sepsis, mechanical ventilation, surgical procedure, postnatal day. NICU, neonatal intensive care unit

Figure 2. Cumulative incidence of receiving at least one plasma transfusion during the first 28 postnatal days of life. Adjusted for the competing risks of death and discharge (presented as cumulative incidence, with corresponding 95% CIs) and based on 468 out of 1143 (40.9%) infants followed from birth. Cumulative incidences of plasma transfusion, discharge and death at day 28 of life do not sum up to 100% due to a portion of infants remaining admitted in the neonatal intensive care unit (NICU) without plasma transfusion.

Figure 3. Primary indications for 177 plasma transfusions. Indications for transfusion were active bleeding (52/177), abnormal coagulation screen results (42/177), or volume replacement/hypotension (38/177), surgical procedures (17/177), prevention of major bleeding (10/177), critically ill conditions (9/177) and other indications (9/177).

Figure 4. (A) Transfusion volume, duration and infusion rate of 52 plasma transfusions given for active bleeding. Colours reflect most common infusion rate within each dot, infusion rates of individual transfusions within one dot may vary as infusion rates were calculated using unrounded transfusion volumes and durations. Transfusion volumes were 5 mL/kg or less in 3.9% (2/52), 10 mL/kg in 26.9% (14/52), 15 mL/kg in 46.2% (24/52), 20 mL/kg in 15.4% (8/52), 25 mL/kg in 5.8% (3/52) and 30 mL/kg in 1.9% (1/52). Transfusion durations were 30 min or less in 5.8% (3/52), 1 hour in 19.2% (10/52), 2 hours in 46.2% (24/52), 3 hours in 21.2% (11/52) and 4 hours in 7.7% (4/52). Transfusion infusion rates were 5 mL/kg/hour or less in 19.2% (10/52), 5–10 mL/kg/hour in 46.2% (24/52), 10–20 mL/kg/hour in 26.9% (14/52) and 20 mL/kg/hour or more in 7.7% (4/52). (B) Transfusion volume, duration and infusion rates of 124 plasma transfusions given for other indications than active bleeding. Colours reflect the most common infusion rate within each dot, infusion rates of individual transfusions within one dot may vary as infusion rates were calculated using unrounded transfusion volumes and durations. Transfusion duration and/or volume were unknown in one transfusion (1/125; 0.8%). Transfusion volumes were 5 mL/kg or less in 0.8% (1/124), 10 mL/kg in 21.8% (27/124), 15 mL/kg in 51.6% (64/124), 20 mL/kg in 23.4% (29/124), 25 mL/kg in 0.8% (1/124) and 30 mL/kg in 1.6% (2/124). Transfusion durations were 30 min or less in 8.9% (11/124), 1 hour in 12.9% (16/124), 2 hours in 36.3% (45/124), 3 hours in 29.0% (36/124), 4 hours in 6.5% (8/124) and 6 hours in 6.5% (8/124). Transfusion infusion rates were 5 mL/kg/hour or less in 17.7% (22/124), 5–10 mL/kg/hour in 54.8% (68/124), 10–20 mL/kg/hour in 16.9% (21/124) and 20 mL/kg/hour or more in 10.5% (13/124).