O1044: Platelet transfusion practices after implementation of a restrictive transfusion guideline in a neonatal surgical population.

Background: Thrombocytopenia (a platelet count < 150x109/L) affects 18-35% of patients admitted to the Neonatal Intensive Care Unit (NICU) and up to 70% of infants born at < 1,000g. Platelet transfusions are often administered to neonates at higher platelet count thresholds than used in older children/adults in hopes of improving outcomes by preventing intracranial hemorrhage. However, in 2019, the PlaNeT-2 trial found an increased incidence of death and/or major bleeding in neonates randomized to a liberal compared to restrictive transfusion threshold. Our group implemented a restrictive platelet transfusion guideline in our Level IV NICU at Boston Children’s Hospital that resulted in meaningful practice change (Davenport et al, 2021). In this study, we investigated platelet transfusion practices specifically in neonates with primary surgical diagnoses, who are cared for by a team of both neonatologists and surgeons, to determine if there was similar practice change with this unique collaborative care team.

Methods: Platelet transfusions administered to infants admitted to the NICU surgical team who underwent at least one operation from January 2017 to December 2020 were classified as either indicated or non-indicated using the new guideline. Transfusions given between January 2017 and December 2018 were “pre-guideline” and those given between January 2019 and December 2020 were “post-guideline.” Patient characteristics, diagnoses, the platelet count prompting transfusion, and the indication for transfusion were collected through retrospective chart review.

Results: 60 surgical patients received 221 platelet transfusions during the study period. There were no differences in the sex, birth weight, gestational age or surgical diagnoses between the pre- and post-guideline groups. The majority of neonates in both periods were treated for necrotizing enterocolitis or spontaneous intestinal perforation. 139 platelet transfusions were given to 37 patients pre-guideline, and 82 transfusions were given to 23 patients post-guideline. The number of guideline-indicated platelet transfusions did not change between periods (51 pre- vs 43 post-guideline, p=0.41) but the number of non-indicated transfusions significantly deceased (73 pre- vs 20 post-guideline, p< 0.0001). The median platelet count prompting transfusion significantly decreased after guideline implementation from 31x109/L (range 3-183x109/L) to 26x109/L (range 6-147x109/L), p=0.0074. No differences were seen in the number of platelet transfusions given for active bleeding in either period (15 transfusions to 7 patients pre- vs 19 transfusions to 8 patients post-guideline, p=0.49).

Conclusion: Platelet transfusions pose risk in neonates and high-quality data from a large, randomized trial supports the use of restrictive guidelines to minimize this harm. In this study, we found that implementation of a restrictive platelet guideline decreased the number of non-indicated platelet transfusions in neonates with primary surgical diagnoses without an increase in transfusions given in the setting of active bleeding.