Plasma transfusions in critically ill children

Abstract

Plasma transfusions are a common treatment in a critical care setting. Physicians mostly prescribe these transfusions to prevent or stop bleeding, as it contains coagulation factors. In massively bleeding patients, plasma transfusions, in association with red blood cells and platelets, have been associated with improved outcome in large observational studies. This indication is currently being assessed by large randomized controlled trials. The evidence is scarcer and less encouraging for the other patients, who are not bleeding massively. In vitro and animal models show that plasma transfusions increase the inflammatory markers. Retrospective studies suggest that plasma transfusions fail to correct mildly abnormal coagulation tests. Furthermore, plasma transfusions are associated with an increased morbidity in critically ill adults and children. However, the majority of plasma is transfused to non-massively bleeding patients. We published a prospective observational study of 831 patients consecutively admitted to a tertiary pediatric intensive care unit over a year. After adjusting for weight, severity at admission, coagulopathy, extracorporeal life support and other transfusions, the odds ratio for increased morbidity was 3.2 (p=0.002). We also published an international survey to evaluate the current practice. Among 187 intensivists from 25 countries, two thirds of pediatric intensivists would prescribe plasma transfusion to non-bleeding patients. We also performed a systematic review, trying to identify randomized controlled trials assessing plasma transfusion strategies. Out of 843 identified records, none evaluated plasma transfusion strategies according to coagulation test thresholds. Finally, we designed a large international observational study, in which we shoed that plasma transfusions only corrected severe coagulopathies. Our next objective is a large randomized controlled trial, evaluating the effect of two different plasma transfusion strategies, one restrictive, the other liberal