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Proposed Guidelines for Platelet Transfusion

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Proposed Guidelines for Platelet Transfusion BCMJ /#47Vol5.final 5/19/05 11:55 AM Page 245 Yulia Lin, MD, FRCPC, Lynda M. Foltz, MD, FRCPC Proposed guidelines for platelet transfusion Physicians can optimize patient outcome and ensure appropriate use of a limited blood supply by following transfusion guidelines. ABSTRACT: The decision to use he guidelines that follow are let transfusions are not indicated in platelet products should be based proposed to support physi- all cases and may be contraindicat- on a careful review of the patient’s T cians in their clinical deci- ed for certain conditions, such as condition and clinical situation. As sions related to the appropriate use of heparin-induced thrombocytopenia well as considering the most up-to- platelet products. They are not intend- and thrombotic thrombocytopenic date guidelines provided by the ed to provide a rigid prescription for purpura/hemolytic uremic syndrome. British Columbia Provincial Blood care and do not replace the need to • Once the cause of thrombocytope- Coordinating Office, the physician consult with an expert in transfusion nia has been established, the deci- should consult with an expert in medicine. The decision to transfuse sion to transfuse platelets should not transfusion medicine. platelets should be based on the judg- be based solely on the patient’s plate- ment of the attending physician after let count. The decision to transfuse Note: An earlier version of these careful review of the patient’s condi- should be supported by the need to guidelines has been published on tion and clinical situation. The goal is prevent or treat bleeding. the Bloodlink BC web site. to optimize patient outcomes and to • Platelet transfusion should be given ensure appropriate use of the allo- only after the risks associated with geneic (donor) blood supply. These transfusion have been considered guidelines apply to platelet transfu- and only when the benefits outweigh sion in adults and are generally applic- the risks. Risks include the general able to children with the exception of risks of transfusion. The physician neonates. should also keep in mind that the These guidelines are periodically risks of bacterial contamination updated and are available electroni- (1:10 000) and alloimmunization to cally on the British Columbia Provin- platelets are increased with platelet cial Blood Coordinating Office web transfusion.1 site (www.bloodlink.bc.ca). Prescrib- ing physicians should refer to the most Drs Lin and Foltz are senior hematology current version of these guidelines. residents at the University of British Colum- bia. These guidelines were commissioned General considerations by the British Columbia Transfusion Medi- • Informed consent is required for the cine Advisory Group (TMAG). TMAG is a transfusion of platelets. technical, medical, and scientific advisory • The cause of thrombocytopenia body to the Ministry of Health in guiding must be established prior to platelet the development of blood program–related transfusion. This is critical as plate- policies in British Columbia. VOL. 47 NO. 5, JUNE 2005 BC MEDICAL JOURNAL 245 BCMJ /#47Vol5.final 5/19/05 11:55 AM Page 246 Proposed guidelines for platelet transfusion • Strategies should be undertaken to of plasma.2,3 The typical platelet pre- Threshold and target minimize the need to transfuse plate- scription is 10 mL/kg to a maximum platelet levels in the lets. For example: of five random-donor platelet units. prevention of bleeding - Investigate, diagnose, and treat Note that each platelet unit is de- As a general guide, the platelet count previously recognized thrombo- rived from a different donor. thresholds shown in theTable should cytopenia. • Single-donor apheresis platelet unit: be used for considering platelet trans- - Discontinue anticoagulants and Each apheresis platelet unit contains fusion.4,5 Serious spontaneous bleed- antiplatelet agents before planned at least 300 ϫ 109 platelets suspend- ing is unlikely to occur at platelet surgery. ed in 200 to 400 mL of plasma and counts >10 ϫ 109/L. More specific - Use adjunctive agents in specific is derived from a single donor.2,3 recommendations are presented in the situations (e.g., desmopressin, anti- Apheresis platelet units are pre- following sections. fibrinolytics). ferred when a patient becomes re- • Ensure that all other coagulation fractory to random-donor platelet For patients undergoing car- parameters are checked as well. units, though the use of single-donor diopulmonary bypass surgery • When platelets are transfused, the apheresis platelet units as first-line The pathophysiology of platelet dys- reasons for the transfusion should platelet products is increasing. function in cardiopulmonary bypass be clearly and accurately recorded (CPB) surgery has not been elucidat- in the patient’s chart and in any doc- Response to ed. Platelet-related bleeding includes umentation used in ordering or ad- platelet products microvascular bleeding as indicated ministering platelets. Typically one unit of random-donor by continued oozing from surgical platelets should increase the platelet incisions and venous cannulation sites. Platelet products count of a 70 kg adult by 5 ϫ 109/L.3 The platelet count following CPB Platelets have a shelf life of 5 days Response to platelet transfusions gives no indication of platelet func- and are stored at 20°C to 24°C with should be assessed by obtaining a tion. Thus, platelet transfusion may be continuous gentle agitation.2 Because platelet count 15 minutes to 1 hour considered in patients who are experi- platelets have a limited shelf life, posttransfusion and calculating the encing excessive postoperative bleed- platelet products are often in short corrected count increment (CCI) as ing and in whom a surgical cause has supply. Most hospitals do not rou- shown in theFigure . been excluded. Consideration for tinely stock platelets, so the transfu- ACCI of >7.5 at 1 hour after trans- transfusion should also be given to sion medicine laboratory should be fusion or >4.5 at 20 to 24 hours after those patients who have recently forewarned, whenever possible, of transfusion is considered acceptable. received antiplatelet agents. Intraop- anticipated platelet requirements. Platelet refractoriness is defined as the eratively, autologous platelet harvest Different platelet products exist, of failure to achieve an expected CCI may be used. There is no role for pro- which the most commonly used are as after two consecutive transfusion epi- phylactic platelet transfusion in CPB.4 follows: sodes.4 Patients who are refractory • Random-donor platelet unit: Each should be assessed further by a trans- For patients with platelet platelet unit contains at least 55 ϫ 109 fusion medicine specialist or hema- dysfunction platelets suspended in 40 to 70 mL tologist. Acquired causes of platelet dysfunc- tion include the use of antiplatelet agents (e.g., ASA, clopidogrel) and renal disease. The platelet count is less CCI = ( posttransfusion platelet count Ϫ pretransfusion platelet count ) ϫ body surface area useful in these situations and the deci- total number platelets transfused sion to transfuse should be based on clinical circumstances. The following 4 Units: recommendations should be imple- pretransfusion platelet count (ϫ 109/L) body surface area (m2) mented in order to avoid platelet trans- posttransfusion platelet count (ϫ 109/L) total number of platelets transfused (ϫ1011/L) fusion if possible: • Discontinue drugs with antiplatelet activity. Figure. Corrected count increment (CCI) calculation. • Consider the use of desmopressin in 246 BC MEDICAL JOURNAL VOL. 47 NO. 5, JUNE 2005 BCMJ /#47Vol5.final 5/19/05 11:55 AM Page 247 Proposed guidelines for platelet transfusion ϫ 9 ϫ 9 Table. Platelet count thresholds for >50 10 /L prior to lumbar puncture >10 10 /L in patients without other platelet transfusion. as platelet counts <20 ϫ 109/L have risk factors such as fever or coagu- been associated with increased risk of lopathy is considered safe. Maintain- Setting Platelet count hematoma or traumatic tap.6,8,9 No ing a lower threshold of 5 109/L or Neurosurgery clear minimum platelet count has been withholding prophylactic transfusion <100 ϫ 109/L CNS trauma identified for the insertion of epidural may be appropriate in selected stable Epidural catheter catheters, with published recommen- patients. Hemorrhage should be treat- <50 Ϫ 80 ϫ 109/L 4 insertion or removal dations ranging from >50 Ϫ 80 ϫ ed with platelet transfusion. 109/L.4,10,11 Significant microvascu- lar bleeding Vaginal delivery can be performed For patients with leukemia or <50 ϫ 109/L Surgery safely with maternal platelet counts undergoing hematopoietic stem Lumbar puncture >50 ϫ 109/L,12 as hemostasis after pla- cell transplantation cental separation is largely mechanical. Patients with acute leukemia (exclud- Vaginal delivery <50 ϫ 109/L Bone marrow biopsy can be per- ing acute promyelocytic leukemia) Thrombocytopenia with <20 ϫ 109/L formed safely without platelet support commonly require platelet transfusion fever or coagulopathy if adequate surface pressure is applied.4 support throughout their treatment Thrombocytopenia due <10 ϫ 109/L Posttransfusion platelet counts course. Several studies have provided to marrow failure should be obtained before any inva- evidence that the threshold for pro- sive procedure. Platelets should be phylactic platelet transfusion can be available for transfusion if bleeding lowered to 10 ϫ109/L.4,13-15 This thresh- patients taking ASA, as well as pa- complications arise. old is similar
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