Platelet transfusions are frequently given to preterm infants to prevent bleeding, but randomized trials demonstrated harmful effects from current practices. Many platelet transfusions were administered in 15–20 mL/kg doses. We sought to decrease platelet exposure among neonates by standardizing 10 mL/kg transfusions for non-bleeding thrombocytopenic infants in a level IV NICU. We created evidence-based platelet dosing guidelines and changed practices in 3 plan-do-study-act cycles focused on education, reinforcement and electronic clinical decision support. We reviewed 240 transfusions over 3 years. The percentage of 10 mL/kg transfusions improved from 17.6% to 100%, without increasing major bleeding and repeat transfusion rates. Monthly transfused platelet volumes decreased from 2269 ± 334 mL to 857 ± 181 mL (p < 0.001), conserving limited platelet resources and saving $2746–$4942 per month in platelets. This study improved our platelet transfusion practices and can facilitate similar transfusion guideline adoption to benefit neonates at other institutions.

Background/Aim: Transfusion can be a life-saving intervention, however routine pre-procedural blood products frequently go unused. Recent national blood product shortages highlight the importance of blood product stewardship. In our pediatric cardiac catheterization laboratory (PCCL), packed red blood cells (pRBCs) were ordered prior to all cases. These units are rarely transfused and sometimes cannot be reallocated, resulting in waste. As a quality improvement project, we set a primary aim to reduce the percentage of monthly pRBC waste from a baseline mean of 7.4% to <5% over 12 months. Methods: Baseline data on all cardiac catheterization cases, excluding electrophysiology, lymphatic, and hybrid cases, were collected from 1/1/2022 to 2/28/2023. Interventions (Table 1) were implemented and outcomes measured from 3/1/2023 to 3/31/2024. Primary outcome measures were monthly percentage of blood wasted, and percent of unused pRBC orders. Emergency blood product activation was measured as a balancing metric. Statistical process control charts were used to display and analyze data. Results: During the intervention period 1,318 cases were performed of which 32% met low-risk criteria for pRBC order de-implementation. The percent of blood that was subsequently wasted was reduced from 7.4% to 5.5% (Figure 1A), primarily driven by the reduction in the anecdotal practice of pRBC unit splitting in patients <1 year old (Figure 1B). The percent of unused pRBC orders was reduced from 97% to 79% with sustained improvement following two cycles of routine blood order de-implementation for low-risk cases. No emergency blood activation occurred (0%, 97.5% CI: 0-0.28%). Conclusion: De-implementation of default pRBC orders for low-risk catheterization procedures and reduction in unit splitting reduced the percent of blood wasted in our PCCL, saving time and cost without compromising patient safety. A data-driven approach to blood stewardship may be broadly applicable across procedural areas.

Previous research suggests that individuals with 22q11.2 deletion syndrome (DS) have an increased risk of bleeding following cardiac surgery. However, current guidelines for management of patients with 22q11.2DS do not provide specific recommendations for perioperative management. This study sought to identify specific risk factors for bleeding in this patient population. Examine the factors determining bleeding and transfusion requirements in patients with 22q11.2DS undergoing cardiac surgery. This was a single center review of patients who underwent cardiac surgery at the Children's Hospital of Philadelphia from 2000 to 2016. Data was extracted from the medical record. Frequency of bleeding events, laboratory values, and transfusion requirements were compared. We included 226 patients with 22q11.2DS and 506 controls. Bleeding events were identified in 13 patients with 22q11.2DS (5.8%) and 27 controls (5.3%). Platelet counts were lower among patients with 22q11.2DS than in control patients, but not statistically different comparing bleeding to not bleeding. Patients with 22q11.2DS received more transfusions (regardless of bleeding status). However, multivariate analysis showed only procedure type was associated with increased risk of bleeding (p = .012). The overall risk of bleeding when undergoing cardiac surgery is not different in patients with 22q11.2DS compared to non-deleted patients. Though platelet counts were lower in patients with 22q11.2DS, only procedure type was significantly associated with an increased risk of bleeding.

Alloimmune hemolytic disease of the fetus or newborn (HDFN) is a rare cause of neonatal cholestasis. HDFN-associated cholestasis has most often been reported secondary to anti-D alloimmunization. In utero transfusions are also an identified risk factor. A variety of diagnostic and therapeutic strategies have been described, mostly in case reports. Here, we report 2 cases of HDFN-associated cholestasis that were notable for extreme laboratory abnormalities including a peak ferritin of 24 700 ng/mL and a peak alanine aminotransferase of 1406 U/L (33.5-fold upper limit of normal). One case was due to alloimmunization other than anti-D. These cases help define the range of laboratory derangements that are consistent with HDFN-associated cholestasis, including extreme hyperferritinemia. Although in a number of cases, researchers have reported the use of iron chelation in these infants, herein, we describe successful management without iron chelation.

BACKGROUND:The AABB (American Association of Blood Banks) and the College of American Pathologists (CAP) regulations call on blood banks to address the risk of misidentification of a patient's blood type, which can result in transfusion of a mismatched product. Transfusion of mismatched blood product is potentially fatal due to acute hemolytic transfusion reaction and is considered a preventable event. CAP regulations outline options to reduce risk of mistransfusion by either documenting the ABO group of the intended recipient on a second sample collected at a separate phlebotomy, or utilizing a mechanical barrier system or electronic identification verification system that ensures the patient from whom the pretransfusion specimen was collected is the same patient who is about to be transfused.STUDY DESIGN AND METHODS:An electronic or barrier system was not available for implementation at our institution, therefore we developed a protocol for a two-sample verification system. The first determination is performed on a current sample and the second by one of the following methods: (a) comparison with previous laboratory records, (b) testing a second sample collected at a time different from the first sample (i.e., laboratory specimen available with a different timestamp, or a new blood sample).RESULTS:We improved our transfusion process and implemented a policy to require a second sample to confirm a patient's blood type. We also implemented workflows to obtain blood type confirmation from history of a second blood type result from previous laboratory records, including a policy to accept previous blood type records from an outside laboratory.CONCLUSIONS:We describe a practice change for two-sample verification for type and screen in a large-scale pediatric hospital. We outline specific workflows for pre-operative and emergency transfusion scenarios, and pediatric-specific challenges.

There are no proven safe and effective therapies for children who develop life-threatening complications of SARS-CoV-2. Convalescent plasma (CP) has demonstrated potential benefit in adults with SARS-CoV-2 but has theoretical risks. We report on the first use of CP in children with life-threatening COVID-19, providing data on four pediatric patients with acute respiratory distress syndrome. We measured donor antibody levels and recipient antibody response prior to and following CP infusion. Infusion of CP was not associated with antibody-dependent enhancement (ADE) and did not suppress endogenous antibody response. We found CP was safe and possibly efficacious. Randomized pediatric trials are needed.

Weber, Mark1; Crowe, Rachael1; Weldon, Rebecca1; Conlon, Thomas1; Friedman, David1 Author Information

There are no proven safe and effective therapies for children who develop life‐threatening complications of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Convalescent plasma (CP) has demonstrated potential benefit in adults with SARS‐CoV‐2, but has theoretical risks.We present the first report of CP in children with life‐threatening coronavirus disease 2019 (COVID‐19), providing data on four pediatric patients with acute respiratory distress syndrome. We measured donor antibody levels and recipient antibody response prior to and following CP infusion. Infusion of CP was not associated with antibody‐dependent enhancement (ADE) and did not suppress endogenous antibody response. We found CP was safe and possibly efficacious. Randomized pediatric trials are needed.

T he hemostatic benefits of transfusing fresh whole blood (FWB) compared to components are controversial for pediatric cardiothoracic (CT) surgical patients as generally reported in the literature. However, of less controversy, a reduction in donor exposure is a uniform finding when FWB is transfused to pediatric CT surgical patients. A pediatric CT program utilizing FWB to reduce transfusion requirements has been in existence since 1995 at The Children’s Hospital of Philadelphia. The combined cooperation of the American Red Cross– Penn Jersey Region in Philadelphia (Red Cross), hospital transfusion service (blood bank), and clinical staff have worked together to sustain this unique program. Furthermore, this Red Cross is the only location of the ARC facilities that currently collects FWB for pediatric CT surgical patients. This collection program has now even extended to hospitals outside our immediate region. This report presents a description of how FWB is requested, obtained, utilized, and monitored in this program.

BACKGROUNDOncology patients are frequent recipients of prophylactic platelet transfusions. Recent studies have demonstrated that lower prophylactic doses of platelets were not associated with a higher incidence of bleeding. At our institution, we found wide variation in platelet dosing due to lack of guidance and support for standardized dosing.STUDY DESIGN AND METHODSA collaborative process improvement project between oncology, hematology, intensivists, and the transfusion service established guidelines for dosing of prophylactic platelet transfusions in nonbleeding oncology patients: 10 mL/kg or less of apheresis platelets for patients weighing up to 20 kg and 1 unit of apheresis platelets patients weighing 20 kg or more, with our stated goal of standardizing transfusion practice. A graphic data display tool that draws on the electronic medical record to monitor platelet ordering was created, with a target goal of greater than 80% compliance with the dosing guidelines. We implemented decision support for dosing consistent with the guideline, and provided educational materials to prescribers at various levels of training within oncology over multiple plan‐do‐study‐act cycles.RESULTSWe were able to consistently achieve between 85 and 90% compliance of prophylactic platelet transfusion orders without an increase in the number of emergency department visits for bleeding or platelet transfusions or changing the time between platelet transfusions after guideline implementation.CONCLUSIONThis project demonstrates that reducing the volume of prophylactic platelet transfusions to doses consistent with published studies was safe and that a process of guideline consensus based on published studies, well‐designed decision support for computerized physician order entry, and targeted educational efforts, were effective in changing practice at a large academic hospital.

Background. Pediatric patients undergoing cardiac operations are at high risk for blood loss and transfusion. A practice intended to reduce transfusion using a standard order of 2 units fresh whole blood (< 48 hours from donation) for elective cardiac operations in patients younger than 2 years of age was in place from 1995 to 2010. The objective of this study was to describe blood use in this population and to compare the results with those in published reports describing the use of blood components exclusively for transfusion.Methods. Retrospective data from a surgical registry and blood bank records for 15 consecutive years were analyzed. Transfusion requirements were identified as donor exposures for the day of operation and the next postoperative day. Transfusions were fresh whole blood, packed red blood cells, platelets, and cryoprecipitate. Donor exposures for subgroups according to procedure and age were compared with those in published reports.Results. The cohort consisted of 4,111 patients with a median age of 94 days and a median weight of 4.4 kg. The median donor exposure was 2 (range, 0 to 28). Younger patients having complex procedures had the most donor exposures. Fewer donor exposures were incurred in all subgroups compared with reports of component use in the literature.Conclusions. The use of fresh whole blood for cardiac operations in children younger than 2 years old reduces donor exposures compared with published reports of component use. (C) 2015 by The Society of Thoracic Surgeons

Key Points Overall, no benefit of granulocyte transfusion therapy was observed, but the power of the study was reduced due to low accrual. Post hoc secondary analysis suggested that patients receiving higher doses tended to have better outcomes than those receiving lower ones.

T follicular helper cells are the main CD4+ T cells specialized in supporting B-cell responses, but their role in driving transfusion-associated alloimmunization is not fully characterized. Reports of T follicular helper subsets displaying various markers and functional activities underscore the need for better characterization/identification of markers with defined functions. Here we show that a previously unidentified subset of human circulating T follicular helper cells expressing TIGIT, the T-cell immunoreceptor with Ig and immunoreceptor tyrosine-based inhibitory domains, exhibit strong B-cell help functions. Compared to the subset lacking the receptor, T follicular helper cells expressing this receptor up-regulated co-stimulatory molecules and produced higher levels of interleukins (IL-21 and IL-4) critical for promoting B-cell activation/differentiation. Furthermore, this subset was more efficient at inducing the differentiation of B cells into plasmablasts and promoting immunoglobulin G production. Blocking antibodies abrogated the B-cell help properties of receptor-expressing T follicular helper cells, consistent with the key role of this molecule in T follicular helper-associated responses. Importantly, in chronically transfused patients with sickle cell anemia, we identified functional differences of this subset between alloimmunized and non-alloimmunized patients. Altogether, these studies suggest that expression of the T-cell immunoreceptor with Ig and immunoreceptor tyro-sine-based inhibitory domains not only represents a novel circulating T follicular helper biomarker, but is also functional and promotes strong B-cell help and ensuing immunoglobulin G production. These findings open the way to defining new diagnostic and therapeutic strategies in modulating humoral responses in alloimmunization, and possibly vaccination, autoimmunity and immune deficiencies.

Patients with sickle cell disease (SCD) often require transfusions to treat and prevent worsening anemia and other SCD complications. However, transfusions can trigger alloimmunization against transfused RBCs with serious clinical sequelae. Risk factors for alloimmunization in SCD remain poorly understood. We recently reported altered regulatory T cell (Treg) and Th responses with higher circulating Th1 (IFN-γ+) cytokines in chronically transfused SCD patients with alloantibodies as compared with those without alloantibodies. Because monocytes play a critical role in polarization of T cell subsets and participate in clearance of transfused RBCs, we tested the hypothesis that in response to the RBC breakdown product hemin, monocyte control of T cell polarization will differ between alloimmunized and non-alloimmunized SCD patients. Exogenous hemin induced Treg polarization in purified T cell/monocyte cocultures from healthy volunteers through the monocyte anti-inflammatory heme-degrading enzyme heme oxygenase-1. Importantly, hemin primarily through its effect on CD16+ monocytes induced an anti-inflammatory (higher Treg/lower Th1) polarization state in the non-alloimmunized SCD group, whereas it had little effect in the alloimmunized group. Non-alloimmunized SCD CD16+ monocytes expressed higher basal levels of heme oxygenase-1. Furthermore, IL-12, which contributed to a proinflammatory polarization state (low Treg/high Th1) in SCD, was dampened in hemin-treated stimulated monocytes from non-alloimmunized SCD patients, but not in the alloimmunized group. These data suggest that unlike alloimmunized patients, non-alloimmunized SCD CD16+ monocytes in response to transfused RBC breakdown products promote an anti-inflammatory state that is less conducive to alloimmunization.

Children are a vulnerable population in the operating room, and are particularly at risk of complications from unanticipated hemorrhage. The decision to prepare blood products prior to surgery varies depending on the personal experience of the clinician caring for the patient. We present the first application of a data visualization technique to study large datasets in the context of blood product transfusions at a tertiary pediatric hospital. The visual analytical interface allows real-time interaction with datasets from 230 000 procedure records. Clinicians can use the visual analytical interface to analyze blood product usage based on procedure- and patient-specific factors, and then use that information to guide policies for ordering blood products.

Introduction Transfusions of packed red blood cell (pRBC) units to infants in Neonatal Intensive Care Units (NICUs) may predispose neonates to healthcare-associated infections (HAIs). We compared neonatal pRBC transfusion practices at four NICUs (Morgan Stanley Children’s Hospital of NewYork-Presbyterian, Columbia University Medical Center, Komansky Children’s Hospital of Weill Cornell Medical Center, Christiana Care Health System, and Children’s Hospital of Philadelphia). In addition, because prolonged refrigerator storage of pRBC may further predispose to HAIs, we tested the hypothesis that an increased mean RBC storage age was associated with a greater risk of infections. Design The interdisciplinary NICU Antimicrobial Prescribing (iNAP) study was conducted in four Level III NICUs from May 2009 to April 2012 to assess HAIs and improve antimicrobial prescribing in NICUs. Eligible infants were admitted <7 days of age and hospitalized ≥4 days. Demographic (e.g., sex, birth weight [BW]) and clinical data (e.g., HAIs and surgical procedures) were collected. HAI included culture negative sepsis defined by treating clinicians, necrotizing enterocolitis, or bacteremia treated for ≥ 4 days. pRBC transfusions were collected from blood bank records at each site. Descriptive statistics were performed using GraphPad Prism 6. Results All sites used irradiated, leukoreduced, CMV negative pRBCs and practiced donor limitation. Blood bank preparation procedures were similar at all sites except that one site stored 3% of units in CPDA-1 in addition to units stored in Additive Solutions (AS), and another site irradiated the parent unit instead of the aliquot; the other sites irradiated the aliquot prior to release. During the study period, 6411 pRBC transfusions were administered to 1381 (21.5%) of 6184 enrolled infants. The transfusion rate was 12.6%, 37.3%, 16.7%, and 25.1% at sites 1-4, respectively. The rate of transfusion by normal BW (≥2500g), low BW (1500-2499g), very LBW (<1500g), and extremely LBW (<1000g) was 0.8, 0.4, 2.8, and 5.5 per patient, respectively. Transfused infants received an average of 4.7 transfusions (range 1-63; average of 3.5, 4.5, 4.5, and 6.0 transfusions at each respective site) with a mean donor exposure of 2.1 (range 1-23). Overall, 50% of pRBC transfusions occurred in the first 17 days of life and 34% occurred during the first week of life. Surgical and post-surgical transfusions accounted for 1389 (21.7%) of 6411 transfusions in 486 (35%) of 1381 transfused infants. Infants undergoing congenital diaphragmatic hernia repair required the most transfusions; 34 infants received 537 ECMO-related transfusions. The average storage age of the pRBC transfused was 16.1 days, but differed by site (12.5, 14.6, 16.7, 19.9 days for each site, respectively, p< 0.001 by Kruskal-Wallis test with Dunns Multiple Comparison Test) and by aliquot (1st-5th aliquot average age 12, 16, 19, 21, and 23 days, respectively). The average age of units transfused in infants without HAIs (n=5693) was 15.2 days; while the average age of units transfused in infants with HAIs (n=491) that developed after transfusion was 15.4 (p=0.04). An ecological study comparing all sites did not find a significant association between the average storage age of units transfused per site (excluding units transfused after onset of infection) and the proportion of neonates with HAIs at the site (R2=0.29; p=0.46; see [Figure][1]). ![Figure][2] Conclusions To our knowledge, this is the largest cohort study of neonatal transfusion practices in Level III NICUs. Transfusion practices were similar at each site. The average storage age of transfused pRBC units varied among the four sites; however, the mean RBC storage age of RBCs transfused to patients with or without HAIs was not markedly different and hospitals with a longer mean storage age did not have a higher proportion of neonates with HAIs. Further analysis is needed to explore the relationship between pRBC storage and HAIs, while controlling for differences in patient characteristics. Disclosures: No relevant conflicts of interest to declare. [1]: #F1 [2]: pending:yes