New York State Council on Human Blood and Transfusion Services GUIDELINES FOR THE ADMINISTRATION OF PLATELETS Third Edition 2012 New York State Council on Human Blood and Transfusion Services New York State Department of Health Wadsworth Center Empire State Plaza – P.O. Box 509 Albany, New York 12201-0509 2012, 2006, 1994 Blood and Tissue Resources Program New York State Department of Health Wadsworth Center Empire State Plaza P.O. Box 509 Albany, New York 12201-0509 Phone: (518) 485-5341 Fax: (518) 485-5342 E-mail: [email protected] Website: www.wadsworth.org/labcert/blood_tissue ii NEW YORK STATE COUNCIL ON HUMAN BLOOD AND TRANSFUSION SERVICES Members (2012) Donna L. Skerrett, M.D., M.S., Chairperson David Huskie, R.N. Chief Medical Officer Petersburg, New York Mesoblast Ltd New York, New York Philip L. McCarthy, M.D. Clinical Blood and Joseph Chiofolo, D.O. Marrow Transplant Director Medical Director, Transfusion Service Roswell Park Cancer Institute Winthrop University Hospital Buffalo, New York Mineola, New York Lazaro Rosales, M.D. Rachel Elder, M.D. Director, Blood Bank Director of Laboratory SUNY Health Science Center Crouse Hospital Syracuse, New York Syracuse, New York Nirav R. Shah, M.D., M.P.H. Alicia E. Gomensoro, M.D. (Ex-officio) Director, Blood Bank Commissioner Maimonides Medical Center New York State Department of Health Brooklyn, New York Albany, New York Kathleen Grima, M.D. Jeanne V. Linden, M.D., M.P.H. Blood Bank Director Executive Secretary The Brooklyn Hospital Center Director, Blood and Tissue Resources Downtown Campus Wadsworth Center Brooklyn, New York New York State Department of Health Albany, New York iii NEW YORK STATE COUNCIL ON HUMAN BLOOD AND TRANSFUSION SERVICES BLOOD SERVICES COMMITTEE Members (2012) Joseph Chiofolo, D.O., Chairperson Patricia T. Pisciotto, M.D. Medical Director, Transfusion Service Chief Medical Officer Winthrop University Hospital American Red Cross Mineola, New York Northeast Division Blood Services Farmington, Connecticut Visalam Chandrasekaran, M.D. * Associate Professor Helen Richards, M.D. School of Health Professions and Nursing Blood Bank Director Long Island University Harlem Hospital Brookville, New York New York, New York Timothy Hilbert, M.D., Ph.D., J.D. † Beth Shaz, M.D. * Medical Director, Blood Bank Chief Medical Officer NYU Langone Medical Center New York Blood Center New York, New York New York, New York Jeanne V. Linden, M.D., M.P.H. * Joan Uehlinger, M.D. Director, Blood and Tissue Resources Director, Blood Bank Wadsworth Center Montefiore Medical Center New York State Department of Health Bronx, New York Albany, New York †Chairperson, Guideline Working Group *Member, Guideline Working Group iv TABLE OF CONTENTS I. Introduction …………………………………………………………………………………………..... 1 II. Benefits of Platelet Transfusion …..……………………..………………………………………….. 1 III. Refractoriness to Platelet Transfusion ………..……………………………………………….…… 3 IV. Adverse Reactions to Platelet Transfusion ………..……………………………………………..... 3 V. Indications for Platelet Transfusion ……………………………………………………………….... 4 A. Prophylaxis in Patients with Platelet Counts <10,000/μL ……………………………….…… 4 B. Prophylaxis in Patients with Platelet Counts <50,000/μL Prior to An Invasive Procedure .. 5 C. Active Microvascular Bleeding Attributed to Platelet Dysfunction or Thrombocytopenia … 5 D. Intrinsic or Acquired Platelet Dysfunction Prior to an Invasive Procedure .………….....….. 5 E. Administration of Platelets at Predetermined Ratio in Massive Transfusion ………….…… 6 Pertinent Literature ……………………………………………………………………………………… 7 General References ……………………………...…………………………………………..……. 7 Thrombocytopenia .…………………………...…..……………………………………………..…. 7 Platelets and Hemostasis ..……………………………………………………………………....... 8 Reactions to Platelet Transfusion .…………..……...……………………………………..……. .9 Alloimmunization ………………………………….....……………….………………..………...... 9 v THIS PAGE LEFT INTENTIONALLY BLANK vi NEW YORK STATE COUNCIL ON HUMAN BLOOD AND TRANSFUSION SERVICES GUIDELINES FOR THE ADMINISTRATION OF PLATELETS I. INTRODUCTION The following guidelines are intended to provide general information about platelet transfusion. Platelets for transfusion are available in two forms: pools of whole blood-derived platelet concentrates, and platelets collected via apheresis. Platelet concentrates are prepared from donated whole blood, separated within eight hours of collection, and contain a minimum of 5.5 x 1010 platelets. The usual quantity transfused to adults is a pool of four to six units, containing a total of 200 to 300 mL of plasma. Individual platelet concentrate units, which contain 40 to 50 mL of plasma, may be used for infants or small children. Apheresis platelets are collected from a single donor and contain a minimum of 3 x 1011 platelets suspended in 200 to 300 mL of plasma. In adults, a pool of four to six whole blood-derived platelet concentrates, or a single apheresis unit, should achieve a clinically meaningful increase in circulating, functioning platelets, and is considered to be a therapeutic dose. Autogeneic transfused platelets have been found to survive four to five days in healthy subjects. However, because 7,000 to 10,000 platelets/ L are consumed daily in plugging endothelial gaps, platelet survival in thrombocytopenic patients is reduced. In order to assess the patient’s response to the transfusion, a corrected count increment (CCI) can be calculated based on the patient’s platelet count 10 to 60 minutes after transfusion and the number of platelets administered (see below). A CCI of >7,500 or a platelet count increase > 5,000/ L per platelet concentrate unit administered is considered an expected response for the transfusion. However, an adequate CCI does not necessarily indicate that a clinically adequate post-transfusion platelet count has been reached. If the increment observed is significantly lower than expected on two or more consecutive occasions, in the absence of infection, splenomegaly, active bleeding, disseminated intravascular coagulation, recent hematopoietic progenitor cell transplant, autoimmune thrombocytopenia, and other circumstances associated with platelet destruction, the patient may be alloimmunized to human leukocyte antigen (HLA) or platelet antigens. Corrected count increment: CCI = (posttransfusion count - pretransfusion count) x body surface area (M2) platelets given x 1011 One unit of platelet concentrate should contain a minimum of 5.5 x 1010 platelets, and one unit of apheresis platelets a minimum of 3.0 x 1011 platelets. The exact platelet count of the transfused component should be used for calculating CCI to assess possible refractoriness. II. BENEFITS OF PLATELET TRANSFUSION Patients who may benefit from platelet transfusion include those with thrombocytopenia (hereditary or acquired) or platelet function disorders (hereditary or acquired). In either situation, platelet transfusions may be prophylactic or therapeutic. Prophylactic platelet transfusions are typically administered prior to an invasive procedure to patients at significant risk for platelet-related bleeding or to patients with severe thrombocytopenia who are at risk for spontaneous bleeding. Patients with autoimmune thrombocytopenia may not respond to platelet transfusions and should receive platelets only in case of life-threatening bleeding. 1 Platelet transfusions are administered to patients who are bleeding or have a potential for bleeding due, at least in part, to either thrombocytopenia or platelet dysfunction. The guidelines below set forth more specific criteria. However, applying the guidelines strictly to individual patients may not always be appropriate. Before a transfusion is ordered, patients should be assessed to determine the likely benefit. The assessment should include determination of the current platelet count, evaluation of any bleeding to determine the likelihood that it is platelet related, and consideration of any co-morbidities that may increase the risk of such bleeding. Most hematologists and transfusion medicine specialists now agree that stable patients generally do not develop significant spontaneous bleeding until the platelet count falls below 10,000/µL. Other factors, such as coexisting coagulopathy, infection, other co-morbidities, and certain medications, may increase the likelihood of bleeding; such high-risk patients should be maintained at higher platelet counts with prophylactic transfusions. The threshold platelet count for thrombocytopenic patients who are to undergo an invasive procedure is less clear. A common practice is to raise the platelet count to at least 50,000/ L, except for procedures involving the central nervous system or eye, for which the count is often increased to at least 100,000/ L. The validity of these numbers is unclear, since few data on this subject are available. Nonetheless, they are generally considered to be adequate platelet counts for most procedures. More problematic is the effect of antiplatelet drugs on the risk of bleeding. For instance, aspirin increases the bleeding time in most patients, although usually not beyond the upper limit of normal. In theory, this should increase the incidence of bleeding, but in practice, that does not appear to be the case, at least in stable patients with no other bleeding risk factors. Desmopressin acetate (DDAVP) improves platelet function in such cases, and platelets are almost never indicated. Drugs such as clopidogrel, abciximab, and other platelet receptor blockers increase the risk of bleeding. Understanding the mechanism