Platelet Transfusion In Children

Types Of Platelets Production

PLT-CONCENTRATES are obtained by centrifugation from whole blood. These are the goods that are most frequently used in platelet transfusions. Another name for them is RDP, or random donor platelets.
50 ml is equal to one unit of PC, and it comprises 5.5–10 x 1010 platelets. It is simpler to use on young children and babies. It is more accessible and less expensive. 

APHERESIS: PLT is the method used to derive them. . Frequently used interchangeably with single donor platelets (SDP). One apheresis platelet unit is equivalent to 300–600 milliliters and has 3 x 1011 platelets in it. There are more platelets overall than RDP products.
Although expensive, it has lessened the likelihood of sensitization as well. . Using this product for repeated transfusions is safer.

Storage Time And Transfusion Time For Platelet Products

At room temperature and 22°C, the typical storage period is five days.
Apheresis products that are kept in strict condition can be kept for up to seven days in storage. The transfusion period should not exceed four hours, nor should it exceed two hours.

Points Regarding Platelet Transfusions From Hematology Texts 

Give Rh+ platelets to Rh-ve patients in an emergency; if this is not possible, use ABO/Rh compatible donor platelets. Because platelets are thermosensitive, they should not be stored in a refrigerator. They should be kept at a constant temperature of 22°C with a constant agitator. Never use glassware with a platelet product.

Points Regarding Neonatal Platelet Transfusions

 Reduced blood products should be given to neonates who need recurrent PLT transfusions in order to lessen HLA alloimmunization, PLT refractoriness, and the risk of transfusion-transmission cytomegalovirus infection (TT-CMV). Radiation therapy is advised to prevent transfusion-associated graft versus host disease (GVHD) in infants weighing less than 1500 grams. If there is a shortage of CMV-negative units, PLT transfusion shouldn't be put off.

Clinical Advice 

The optimal time to use platelets for transfusion is different for sick children than for healthy children; reduced production of platelets is preferable to higher consumption. Compared to a child who simply has skin bleeding, a child who has mucosal bleeding needs platelets transfusion more frequently. In comparison to only skin bleeds, it is a more powerful indicator.

Indications 

 Baby under four months old. If the patient is bleeding or is receiving ECMO, maintain a platelet count of greater than one lakh/cc. If this count is less than 1 lakh/cc, transfusion is performed. When undergoing invasive operations, keep your platelet count above 50,000/cc.
If the patient is clinically unstable or using medication that affects platelet function, such as indomethacin, NO, antibiotics, etc., maintain a platelet count > 50000/cc. If the platelet count is clinically stable, keep it above 20,000/cc. If a patient has bleeding or invasive surgical procedures-related platelet functional abnormalities, platelet transfusions are also required at any level.

In case of older children and adolescents - 

• Maintain platelet count > 50000/cc if bleeding is present.
• Maintain platelet count > 50000/cc in invasive procedures.
• Maintain platelet count > 25000/cc in minor procedures.
• Maintain platelet count > 20000/cc if bone marrow failure is present with hemorrhage risk factors.
• Maintain platelet count > 10000/cc if bone marrow failure without hemorrhage risk factors.
• Platelet transfusions are also needed at any level, if the patient is having platelet functional defects with either bleeding/invasive surgical procedures.

According To Nelsons

To surpass 50,000 platelets per cubic millimeter. Standard platelet concentrates (5–10 mL/kg) can be administered to youngsters up to 30 kg in weight. One apheresis unit or four to eight pooled platelet concentrates is the recommended dosage for large children.

Concept Of Corrected Count Increment 

 The kind of platelet dysfunction is predicted by the corrected count increment (CCI), which is used to assess the effectiveness of platelet transfusions. The CCI is measured after one hour after transfusion, and a second CCI value is computed 24 hours later by. After-transfusion platelet count, or CCITransfusion-related platelet count. Platelets/m2 injected with 1011 BSA.

Normal CCI is greater than 4.5 x 109/L at 20–24 hours and greater than 7.5 x 109/L at 1 hour. Patients with consumption coagulopathy are present if the CCI is normal at one hour but low at twenty-four. Immune damage is observed in patients whose CCI value is low even after one hour. 

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Contraindication For Platelet Transfusion

The illness is known as thrombotic thrombocytopenic purpura and HUS spectrum. Hypersplenism and immunological destruction (acute ITP) cannot be treated with platelets.

Q: A neonate needs to be administered platelet concentrates but the resident is afraid it may cause volume overload. Should additional centrifugation be done to reduce volume even further?

No. It is not essential nor wise to routinely reduce the volume of PLT concentrates for newborns and small children by additional centrifugation processes. It is sufficient to transfusion 10–15 mL/kg of an unaltered PLT concentrate. 

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Types Of Plasma Products 

Fresh Frozen Plasma (FFP): Plasma that is extracted and stored at a low temperature for no more than eight hours.  F24: After being collected, the plasma is frozen in less than 24 hours.
Factor V and VIII levels in this are somewhat lower than FFP. 

Points To Remember Regarding FFP

If stored correctly, it has a one-year shelf life. Thawed in the water bath for 30 minutes at 37 degrees Celsius. For hemophilia A, thawed FFP should be used within 4 hours, and for other deficits, it should be used within 24 hours. 200–250 ml of plasma = 200–250 units of clotting factors equals one unit of FFP. Clotting factors are equal to one milliliter of plasma (ml^2). The recommended dosage is 10–15 ml/kg. It is repeatable once every twelve hours.

Hemostatic Content Of 1 Unit Of FFP

• Fibrinogen is 2.67 mg/ml.
• The unit of FFP contains factor II, factor V, and vWF = 80 IU/ml each.
• Factor VII = 90 IU/ml.
• Factor VIII = 92 IU/ml.
• Factor IX, XI,XIII, AT-III = 100 IU/ml each.
• Factor X = 85 IU/ml.
• Factor XII = 83 IU/ML.

Plasma Transfusion Indications

Severe bleeding and clotting factor deficiency. Invasive operations and severe clotting factor deficit are required. Warfarin's emergency reversal of effects. Massive transfusion-related hemorrhage and dilutional coagulopathy. Anticoagulant proteins, such as proteins C and S and antithrombin III. FFP can be utilized as a replacement fluid for plasma exchange in TTP, as well as in conditions where bleeding is obvious or when deficiencies in clotting proteins increase the risk of bleeding (liver failure, for example).

Indications In Neonates

FFP can be utilized in reconstitution procedures involving PRBC, including as cardiac bypass surgery, DVET, and ECMO.  Severe bleeding linked to a vitamin K deficiency. A bleeding DIC.
As an emergency, bleeding with a possible congenital coagulation factor deficiency. Not used in partial exchange transfusion or to avoid IVH. 

Points To Note

 FFP shouldn't be the only treatment utilized in hypovolemia to increase volume. A better method for expanding volume than FFP is albumin infusion. Factor concentrates are preferable to FFP in certain cases of factor deficiency. FFP can be used to treat and prevent coagulopathy brought on by L-asparaginase in all patients. FFP can be used in conjunction with other factor deficiencies, such as DIC and severe liver disease.

Cryoprecipitate

 To prepare it from FFP, thaw it to 1-6 °C, centrifuge it, and collect the precipitate. After re-suspension of the precipitate in a small volume of leftover plasma (usually 10–15 ml), it is frozen again for storage. For a year, it can be kept at or below -18°C. It lacks factor IX and other factors, although it does contain fibrinogen, vWF, and factors VIII and XIII.  Has more fibrinogen in it than FFP.  Cryoprecipitate can be utilized in hemophilia B patients; however, it is not as successful as FFP in patients with afibrinogenemia.

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