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Use of Platelets in Transfusion Medicine

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Use of Platelets in Transfusion Medicine Use of platelets in transfusion medicine DANIEL B. BRUBAKER, DO Platelet transfusions are bene- mittee on Hospital Transfusion Practices pub- ficial to treat or prevent bleeding in the lished guidelines for the improvement of blood thrombocytopenic patient. They are fre- transfusion practices.4 At the same time, the quently used in patients with hypoplastic Joint Commission on Accreditation of Hospi- bone marrow, in cardiovascular surgery tals5 mandated an evaluation of the appropri- patients, and those involved in trauma. Be- ateness of all blood component transfusions cause platelets have short survival, large that their inspections closely evaluate. More numbers of platelet units are required. recently, a National Institutes of Health (NIH) Also, platelet transfusions are expensive Consensus Conference convened to address vari- and not without complications. They can ous issues in platelet therapy. 6 The wide dis- cause alloimmunization, provoke transfu- semination that the AABB guidelines and con- sion reactions, or transmit infectious dis- sensus report have received will lead to im- ease, of which hepatitis C (non-A, non-B proved platelet use. However, there is a con- hepatitis) is of greatest concern. Therefore, tinuing lack of consensus in many areas of documented indications and close moni- platelet therapy because of a lack of under- toring of the transfused platelets are nec- standing of platelet function. essary. Platelets are cell fragments with disk-like structures that prevent bleeding. Their func- tion in hemostasis is to adhere to the suben- The availability of platelet concentrate trans- dothelial collagen microfibrils during vascu- fusions in the 1960s led to a considerable re- lar injury, secrete adhesive proteins, activate duction in death due to hemorrhage in leuke- other platelets to aggregate, and induce the mia patients. From 1971 to 1980, platelet us- intrinsic coagulation pathway. age increased nearly 600% as new indications Normal adults have 150,000 to 450,000 plate- were explored. 2 However, recent audits have lets per cubic millimeter in the circulation. If shown that 40% of all platelet transfusions either the number of platelets is reduced or were used inappropriately. 3 In 1985, the Ameri- the function is abnormal, bleeding may result. can Association of Blood Banks (AABB) Com- In vivo platelet function can be assessed by measuring the in vivo bleeding time. Patients are not very compliant with the test, and there is a large coefficient of variation with a nor- Dr Brubaker is assistant professor, UCLA School of Medi- mal bleeding time between 2 and minutes; cine, Los Angeles, and head of transfusion medicine labo- 8 ratory and diagnostic immunology, department of pa- therefore, a standardized test of platelet func- thology, Harbor-UCLA Medical Center, County of Los tion is needed. Bleeding, however, does not usu- Angeles, Torrance. ally occur unless the bleeding time is twice normal. In general, a platelet count of 50,000/ The views expressed herein are those of the authors and do not necessarily reflect the views of the county ',LI, is adequate for hemostasis. Spontaneous of Los Angeles Department of Health and Human Serv- hemorrhage does not occur unless the platelet ices or the University of California. count is less than 10,000/RL. Thrombocytopenic bleeding is unique in Reprint requests to Daniel B. Brubaker, DO, depart- ment of pathology, Harbor-UCLA Medical Center, 1000 that bleeding arises from small vessels and cap- W Carson St, Torrance, CA 90509. illaries of the skin and mucosa. The severest Clinical practice • Brubaker JAOA • Vol 89 • No 12 • December 1989 • 1553 Table 1 such as induction chemotherapy for acute leu- Indications for Platelet Transfusions kemia, but not to those with chronic myelo- suppression, that is, aplastic anemia.6 Need for Diagnosis platelet transfusions Prophylactic platelet transfusions are given to decrease patient morbidity with bleeding epi- • Thrombocytopenia due to Useful to treat or pre- sodes. They do not decrease mortality due to decreased production: vent bleeding Leukemia—postinduction of bleeding and require twice the number of trans- chemotherapy fused platelets for therapeutic results. 8'9 This Bone marrow transplantation Aplastic anemia issue will remain controversial until reliable, Myelofibrosis/chronic myelog- well-controlled studies solve the dilemma. enous leukemia If surgery or invasive procedures such as lum- • Dilutional thrombocytopenia Needed when platelet bar puncture or liver biopsy are necessary, (as in massive transfusion) count < 50,000 or in platelet transfusions are required to raise the excessive bleeding platelet count above 50,000/11L. Platelets are • Thrombocytopenia due to in- Not indicated unless not required if the platelet count is above creased destruction: bleeding is life- Idiopathic thrombocytopenic threatenting 50,000/p L, and the bleeding time is less than purpura twice the upper limit of normal (12 minutes).6 Thrombotic thrombocytopenic purpura Adjunctive therapy may also be beneficial Hemolytic uremic syndrome and may decrease the number of platelets trans- • Platelet function abnormality Only after corrected fused. Epsilon aminocaproic acid (Amicar), an (as in uremia and plasma functional defect antifibrinolytic agent, may decrease sponta- cell dyscrasias) neous bleeding. 10 A preparation of conjugated estrogens (Premarin) can also be used in women to suppress menstruation and menor- form of thrombocytopenic bleeding is intra- rhagia. Vitamin K is useful to prevent coagu- cerebral bleeding, which may be rapidly fatal. lation factor deficiency, particularly in patients Factors that exacerbate bleeding in thrombocy- on antibiotics who are not eating. 11 Bleeding topenic patients include a rapid fall in plate- in uremic patients responds to cryoprecipitate let count, fever, sepsis, certain medication such or desmopressin acetate (DDAVP), so that the as aspirin, vomiting, uremia, concomitant co- use of platelet transfusions can be eliminated agulation factor deficiency, and trauma. in such cases. Dilutional thrombocytopenia from massive Indications for platelet transfusions blood transfusions, as in trauma, does not pre- Platelet transfusions are indicated for bleed- sent a problem for two reasons: (1) microvas- ing patients with thrombocytopenia due to de- cular bleeding does not develop; and (2) plate- creased marrow production (Table 1). A di- let counts usually do not drop below 50,000/ lemma occurs in the prophylactic use of plate- pi.L. More than 30 units of blood must be trans- let transfusion. Some authorities 6 believe that fused before the platelet count drops below no prophylactic platelet transfusions are indi- 50,000/RL, or there must be coexisting dissemi- cated, whereas others give platelets routinely nated intravascular coagulopathy (DIC). In the when the patients count drops below 20,000/ majority of patients receiving 10 to 20 units 1.11. This cutoff number originated from the of blood, bleeding problems do not develop; how- 1960s and 1970s when most patients were ever, a platelet count should be taken after treated for fever with aspirin. Because ace- every 12 to 15 units of blood, with platelet trans- taminophen is currently used, the suggested fusions reserved for thrombocytopenic patients level may be lowered to 10,000 7 or even 5000/ and patients with microvascular bleeding.2 LAL (I recommend 10,000/g,L). Prophylactic plate- Patients who have thrombocytopenia due to let transfusions have been recommended only peripheral destruction, such as in idiopathic to patients with transient myelosuppression (immune) thrombocytopenic purpura (ITP) or 1554 • JAOA • Vol 89 • No 12 • December 1989 Clinical practice • Brubaker thrombotic thrombocytopenic purpura (TTP) Platelet products, dosage, and do not benefit from platelet transfusions.13 administration Transfusion of platelets in TTP accentuates Platelets are prepared and concentrated by two the disease and can cause rapid demise. Be- methods. Random donor or unrelated platelet cause hemolytic uremic syndrome (HUS) is concentrates are prepared at the community very similar to TTP, results would be similar. blood center or Red Cross from individual units Idiopathic thrombocytopenic purpura rapidly of whole blood." The platelet concentrates destroys platelets because of an autoimmune have about 0.5-1.0 x 1011 platelets in 50 ± antibody toward platelets. The only indication 10 mL of plasma. These units are frequently for platelet transfusions in ITP and TTP pa- combined as 6-, 8-, 10-, or 12-unit pools. tients is in life-threatening bleeding such as The second platelet product is prepared from CNS bleed. 12 Disseminated intravascular co- blood drawn from single donors connected to agulation is more controversial. In my opin- an apheresis instrument, such as Fenwal CS- ion, the underlying cause for DIC should be 3000, Cobe Spectrum III, or Haemonetics S-30 treated and the patient supported with plate- instruments. The platelets are separated from let and cryoprecipitate transfusions. the rest of the blood elements and concentrated Cardiac surgery presents further problems to give approximately 5 x 10 11 platelets in one in the use of platelet transfusions. One study14 bag. Such products are called single donor plate- has shown no correlation between the platelet let concentrates, single donor units, or count and intraoperative or postoperative bleed- plateletpheresis units, and each is equivalent ing in patients undergoing cardiac surgery.
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