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PubMed2006

Postnatal management of fetal and neonatal alloimmune thrombocytopenia: the role of matched platelet transfusion and IVIG.

We evaluated the effects of platelet transfusions and intravenous immunoglobulin (IVIG) in neonates with fetal and neonatal alloimmune thrombocytopenia (FNAIT) with and without antenatal treatment with IVIG. Records of neonates with FNAIT admitted between January 2000 and November 2005 were reviewed. The patients were divided into group I, treated antenatally with IVIG for known FNAIT, and group II, postnatally diagnosed with FNAIT. The primary outcome was the time interval to reach a platelet level above 100 x 10(9)/L in relation to the type of treatment. Nineteen neonates with FNAIT were identified, 13 in group I and 6 in group II. In group I, four children were born with a platelet count above 100 x 10(9)/L and never needed treatment, and four received a single matched platelet transfusion at birth with a maintained response. Five neonates received IVIG and one matched transfusion, with all but one rapidly responding. In antenatally treated cases, postnatal IVIG had no apparent effect on the platelet count. In group II, two neonates died on day 1 with severe intracranial hemorrhage. Two of the four other patients responded to a number of unmatched platelet transfusions, with one neonate rapidly responding after one matched transfusion, while another needed nine matched transfusions before a persistent adequate platelet count was reached after 9 weeks. Postnatal IVIG had no apparent effect on the platelet count in any of our cases. In neonates with FNAIT treated antenatally with IVIG, neonatal management using a single matched platelet transfusion was adequate in all cases. In neonatally diagnosed cases not treated before birth, multiple matched platelet transfusions may be required. We found no evidence to support the use of IVIG in neonates with FNAIT.

Female↗

PubMed2002

Multicenter analysis of platelet transfusion usage among neonates on extracorporeal membrane oxygenation.

OBJECTIVE: Multiple platelet transfusions are invariably given to neonates on extracorporeal membrane oxygenation (ECMO), and no alternative to repeated transfusions exists. Before any alternatives, such as administration of thrombopoietic stimulators, could be contemplated, data regarding the number of platelet transfusions received by neonatal ECMO patients is needed, and the mechanisms that cause the thrombocytopenia of these patients must be better defined. As a step toward determining this, we analyzed the use of platelet transfusions in this group of neonates. We conducted a historic cohort study of neonates who were treated with ECMO to determine the number of platelet units received as a function of 1) days on ECMO, 2) medical diagnosis for which ECMO was instituted, and 3) type of ECMO used (venovenous [VV] vs venoarterial [VA]). METHODS: We reviewed the hospital records of all neonates who were admitted to the neonatal intensive care units at Shands Children's Hospital, Arnold Palmer Hospital for Children and Women, and Tampa General Hospital and treated with ECMO between January 1, 1995, and June 30, 2000. Data were expressed as the number of platelet transfusions versus number of days on ECMO, diagnosis for which ECMO was instituted, and type of ECMO used. RESULTS: Of the 234 ECMO patients, 81 were placed on VV, 138 were placed on VA, and 15 were converted from VV to VA. The average number of platelet transfusions received per day was 1.3 and varied by diagnosis and by type of ECMO. Neonates with meconium aspiration and sepsis required more platelet transfusions per day than neonates with other conditions. Infants who were converted from VV to VA required more transfusions per day (mean: 1.57) than did patients on VA (1.47) or VV (1.06). CONCLUSIONS: Platelet transfusions among neonates on ECMO are dependent of their medical diagnosis; they average 1.3 transfusions per day and are higher on VA than VV ECMO.

Birth Weight↗

PubMedDate not supplied

Platelet transfusion refractoriness associated with two rare platelet-specific alloantibodies (anti-Baka and anti-PlA2) and multiple HLA antibodies.

A 65-year-old patient with pancytopenia resulting from osteomyelosclerosis became refractory to platelet transfusions during long-time transfusion support. He developed two rare, platelet-specific antibodies (anti-PlA2 and -Baka) disguised by strong, multispecific HLA antibodies. The specificity of the platelet-specific antibodies was detected by a newly designed enzyme-linked immunosorbent assay using glycoprotein-specific monoclonal antibodies for immobilization of platelet antigens.

Aged↗

PubMed1998

A clinical audit on the practice of platelet transfusions at a tertiary paediatric referral centre.

Platelet transfusions are indicated in a wide variety of clinical conditions especially those with thrombocytopenia. However, without proper clinical practice guidelines, inappropriate transfusions are bound to happen. To ascertain the provision of a quality and appropriate practice of platelet transfusions, an audit study was carried out over a period of one month at the Paediatric Institute, Kuala Lumpur Hospital. A prospective audit was performed during that period whilst a retrospective collection of data was carried out for the previous month for comparison. Based on a set of criteria agreed upon by the audit committee, it was found that in 18.5% (22 of 119) of the cases, the indications for platelet transfusions were inappropriate. The audit committee concluded that there is a need for a more detailed clinical practice guideline for local use to reduce or lower the incidence of inappropriate transfusions of platelets.

Child, Preschool↗

PubMed2003

Prophylactic platelet transfusions: which dose is the best dose? A review of the literature.

Routine platelet transfusions for patients with acute leukemia were introduced in the early 1960s, and since then platelet use has increased steadily. Despite widespread use, good clinical evidence supporting prophylactic platelet transfusions is limited, and there are very few studies that have examined the dose for prophylactic platelet transfusions. Review of the platelet dose used in both early studies of routine platelet transfusions and more recent clinical trials of platelet transfusions shows wide variation in dosing, which is also reflected in clinical practice. As such, only limited recommendations for platelet dose have been forthcoming from consensus conferences or guidelines. The results from 3 recent clinical trials and a mathematical model examining the dose for prophylactic platelet transfusions suggest that lower dose transfusions may decrease the total number of platelets transfused; however, no definitive conclusions about the optimal platelet dose can be reached as these trials were not designed to evaluate bleeding outcomes or total platelet utilization. Future large clinical trials of platelet dose, which examine these critical outcomes, are required. Only with these results can the optimal platelet dose be determined.

Blood Donors↗

PubMed2002

Significance of platelet-reactive antibody screening for patients facing frequent platelet transfusions.

It is not clear whether platelet-reactive antibody screening is clinically significant for patients facing frequent platelet transfusions. On the basis of data from 96 patients who had been examined for platelet-reactive antibodies by the mixed passive hemagglutination method for a variety of reasons, we investigated the following three issues retrospectively: (1) the relationship between platelet-reactive antibodies and the occurrence of problems in platelet transfusions, such as refractoriness or nonhemolytic reactions; (2) the influence of a history of transfusion on the production of those antibodies; and (3) the effect of screening for those antibodies on the prompt administration of appropriate platelet components. More than half of the platelet transfusion-related problems were associated with platelet-reactive antibodies. For patients with a history of transfusion, the mean period before a clinical problem occurred with platelet transfusions was 9 days,compared with 66 days for those without such a history. Accordingly, during the period, patients with a history of transfusions received fewer units of platelets and had fewer donor exposures than did patients without such a history. On the other hand, most patients who had been screened in advance for those antibodies received appropriate platelet components without delay, whereas an average of 10 days was needed before those who had not been screened received compatible platelets. The patients who had not been screened were transfused with 68 units of random platelets on average during the period. When frequent platelet transfusions are anticipated, especially for patients with a history of transfusion, screening for platelet-reactive antibodies beforehand would be helpful for prompt administration of appropriate platelets, although problems, such as the cost of those platelets and the burden on donors, remain to be resolved.

Journal Article↗

PubMed2005

Compliance with prophylactic platelet transfusion trigger in haematological patients.

The aim of prophylactic platelet transfusions in haemato-oncologic patients with thrombocytopenia is to prevent bleeding. Currently, a platelet transfusion trigger of 10 x 10(9) L(- 1) is considered to be safe. Transfusion compliance with this trigger can save costs. To investigate the compliance with this trigger of 10 x 10(9) L(- 1), we have evaluated 1447 platelet transfusions given during a period of 1 year to haematological patients. In half of the transfusions, there had been compliance with the trigger of 10 x 10(9) L(- 1). About three-quarters of all platelet transfusions were given at platelet counts < or =20 x 10(9) L(- 1). Transfusions at levels >20 x 10(9) L(- 1) were usually performed because of bleeding, scheduled interventions or concurrent anticoagulant therapy. We conclude that compliance with the prophylactic platelet transfusion trigger of 10 x 10(9) L(- 1) was about 50%; however, deviation from the trigger was partly explained by risk factors that justify a higher transfusion trigger.

Guideline Adherence↗

PubMed1980

Platelet transfusion therapy and circulating immune complexes.

30 platelet transfusions were administered to 9 thrombocytopenic patients with acute leukemias. Using the Raji cell radioimmunoassay, the serum concentration for circulating immune complexes (CIC) were determined immediately before and 10--12 h after each transfusion therapy. Elevated serum concentrations for CIC were present in 14 of the pretransfusion samples. After platelet transfusion therapy, a significant (p < 0.02) decrease in the values of CIC occurred. In these 14 transfusion studies the mean percent platelet increment was considerably lower (0.10 > p > 0.05) than the mean for the 16 transfusion studies in which the pretransfusion values for CIC were normal. These results show that CIC probably play an important role in removing transfused platelets from the circulation. Conversely, platelets are able to remove CIC from the circulation.

Acute Disease↗

PubMed1998

Apheresis platelets: emerging issues related to donor platelet count, apheresis platelet yield, and platelet transfusion dose.

Emerging issues in stimulating apheresis platelet donors with platelet growth factors, the relative costs of apheresis and random donor platelet concentrates, optimal platelet transfusion dose, and leucoreduction of platelet products have caused renewed debate regarding apheresis products vs. random, pooled concentrates. The future role of apheresis products in platelet transfusion therapy will in large part be determined by costs, which are increasingly recognized to be influenced by donor platelet count, apheresis yield, and platelet transfusion dose.

Blood Donors↗

PubMed2001

Platelet transfusions in the neonatal intensive care unit:factors predicting which patients will require multiple transfusions.

BACKGROUND: Previous studies suggest that recombinant thrombopoietin (rTPO) will increase platelet production in thrombocytopenic neonates. However, the target populations of neonates most likely to benefit should be defined. Studies suggest that rTPO will not elevate the platelet count until 5 days after the start of treatment. Therefore, the neonates who might benefit from rTPO are those who will require multiple platelet transfusions for more than 5 days. This study was designed to find means of prospectively identifying these patients. STUDY DESIGN AND METHODS: A historic cohort study of all patients in the neonatal intensive care unit (NICU) at the University of Florida who received platelet transfusions from January 1, 1997, through December 31, 1998, was conducted. RESULTS: Of the 1389 patients admitted to the NICU during the study period, 131 (9.4%) received platelet transfusions. Seventeen were treated with extracorporeal membrane oxygenation and were excluded from further analysis. Of the remaining 114 patients, 55 (48%) received one transfusion and 59 (52%) received more than one transfusion (21 had >4). None of the demographic factors examined predicted multiple platelet transfusions. However, two clinical conditions did; liver disease and renal insufficiency. Neonates who received one platelet transfusion had a relative risk of death 10.4 times that in neonates who received none (p = 0.0001). Neonates who received >4 platelet transfusions had a risk of death 29.9 times that in those who received no transfusions (p = 0.0001). CONCLUSION: NICU patients with liver disease or renal insufficiency who receive one platelet transfusion are likely to receive additional transfusions. Therefore, these patients constitute a possible study population for a Phase I/II rTPO trial.

Cohort Studies↗

PubMed1996

Factors associated with response to platelet transfusion following hematopoietic stem cell transplantation.

We studied 526 consecutive post-transplant platelet transfusions to determine the factors associated with response to platelet transfusion in the BMT setting. Poor responses to platelet transfusions occurred frequently, with 310 of the 484 evaluable transfusions (64%) resulting in post-infusion corrected count increments of less than 7500. Factors associated with poor response to platelet transfusion by both univariate and multivariate analysis included, (1) presence of serum lymphocytotoxic antibodies; (2) male sex; (3) body surface area greater than 1.7 m2; (4) transfusion of red cells on the day of the platelet infusion; (5) concurrent administration of steroids; (6) major ABO mismatch between the recipient and the platelet product; and (7) (among women) a history of one or more pregnancies prior to transplant. Paradoxically, a history of greater than 25 blood product exposures prior to transplant, and evidence of prior CMV infection in either the bone marrow donor or recipient were associated with higher CCIs by both univariate and multivariate analysis. Factors that showed little correlation with response to platelet transfusion included, (1) age of the infused platelet product; (2) concurrent fever; (3) recent administration of intravenous immunoglobulin; and (4) absolute neutrophil count at the time of the infusion. The factors associated with response to platelet transfusion in BMT patients appear to be different from those observed in the non-transplant setting.

ABO Blood-Group System↗

PubMed2004

A rapid platelet function assay used to regulate platelet transfusion prophylaxis following cardiopulmonary bypass surgery.

Subsequent to cardiac surgery with cardiopulmonary bypass (CPB), patients are at risk of postoperative bleeding caused by acquired defects associated with the procedure. As such, many patients receive prophylactic blood product transfusion. The effectiveness of measuring platelet function using a near-patient platelet function analyzer for the purpose of regulating platelet transfusion and potentially modulating other blood products including fresh frozen plasma (FFP) and cryoprecipitate (CRYO) transfusion was evaluated prospectively in patients undergoing CPB. A 6-month prospective study was designed that encompassed all CPB patients at Aultman Hospital (Canton, OH) during 2001. Each patient was assessed postoperatively for platelet count and function using a point-of-care analyzer. Data were used to help determine whether a platelet transfusion would be administered. Transfusion of CRYO and FFP was also recorded. The data were then compared to the retrospective same 6-month period in the preceding year for the purpose of determining the value of this system in guiding transfusion triage. There were 1770 platelet packs transfused during the study period, representing a 34% reduction in platelet usage. Platelet transfusions were reduced by 51% (5.75 in 2001 vs. 11.75 in 2000) per patient. CRYO/FFP usage was also substantially reduced. During the study period, the patient caseload had increased by 72 (310 vs. 238). Monitoring platelet count and function as a result of CPB and administering an appropriate transfusion protocol can positively impact transfusion outcome.

Autoanalysis↗

PubMed2001

New strategies for prophylactic platelet transfusion in patients with hematologic diseases.

There is an increasing demand for platelet transfusions due to intensive chemotherapy and blood stem cell or bone marrow transplantation for the treatment of hematologic and oncologic diseases. There has been a long-lasting debate over whether the traditional threshold for prophylactic platelet transfusion of 20,000/microl is really necessary to prevent hemorrhagic complications. During the last 10 years several studies with more than 1,000 patients together have proven the safety of a platelet transfusion trigger of 10,000/microl or even lower when patients are clinically stable without active bleeding. This experience has been mostly gathered in patients with acute leukemia. But this stringent platelet transfusion policy can be used also after blood stem cell and bone marrow transplantation. In stable patients with aplastic anemia and myelodysplasia, prophylactic transfusions should be replaced in most patients by a therapeutic transfusion strategy. Such restrictive platelet transfusion strategies decrease the risk of infectious disease transmission, immunization, and febrile transfusion reactions. Besides reduced hospital visits and a shorter hospital stay for the patients, the costs for platelet transfusions are lowered by 20%-30% compared with traditional transfusion strategies. The decision to administer platelet transfusions should incorporate individual clinical characteristics of the patients and not simply be a reflexive reaction to the platelet count. Further clinical studies are needed to answer the still open question of whether patients with acute leukemia should also be transfused therapeutically rather than prophylactically when they are in stable condition without signs of active bleeding.

Anemia, Aplastic↗

PubMed1988

Clinical factors influencing the efficacy of pooled platelet transfusions.

To determine the relative importance of clinical factors on the efficacy of platelet transfusions, 941 pooled platelet transfusions from HLA-unmatched donors were studied prospectively in 133 patients with bone marrow failure. Multiple linear regression analyses identified the major factors influencing one-hour-corrected increments (CI) as prior splenectomy, bone marrow transplantation, disseminated intravascular coagulation, concurrent intravenous amphotericin B, splenomegaly, and HLA antibody grade. The relative impact of these factors on CI has been quantitated by using a formula developed from these data. A linear relationship was demonstrated between increasing percentage of HLA antibody grade and decreasing CI. A number of other factors were less important in the linear regression model than the aforementioned major factors. These included platelet-specific antibodies, concurrent antibacterial antibiotics, clinical bleeding grade, and temperature. Factors that did not influence CI included the number of prior platelet transfusions, prior granulocyte transfusions, prior red cell transfusions, infection, age, blood group, diagnosis, sex, pretransfusion platelet count, prior pregnancies, and concurrent antineoplastic drugs. This study identified major clinical factors that significantly influenced CI and were major causes of refractoriness to pooled platelet transfusions.

Antibodies↗

PubMed2003

Immune and nonimmune causes of low recovery from leukodepleted platelet transfusions: a prospective study.

Alloantibodies against HLA antigens can be reduced by applying leukodepletion to transfusions. Because the importance of immunological and nonimmunological causes of poor platelet transfusion results using leukodepleted transfusions is not clear, we conducted a prospective study in an unselected patient population receiving leukodepleted transfusions. In 97 patients with hematological malignancies, 181 random leukodepleted platelet transfusions were studied for immunological causes of poor platelet transfusion results by calculating the odds ratio of four different screening tests for a low platelet recovery. Nonimmune causes were also studied by calculating the odds ratio of the most prevalent nonimmune causes for a low platelet recovery. No single screening test showed an association with recovery after 1 and 16 h following a platelet transfusion. The combination of a positive enzyme-linked immunosorbent assay (ELISA) and platelet immunofluorescence test (PIFT) or a combination of a positive lymphocyte immunofluorescence test (LIFT) and PIFT, demonstrating an association with a low platelet recovery after 16 h, was present in 2% of all platelet transfusions. Of nonimmune causes, splenomegaly and storage time of platelets for more than 3 days were associated with low platelet recovery after 1 h and 16 h of being present in 29% and 47% of all platelet transfusions, respectively. Immunological causes account for a small proportion of poor platelet transfusion results compared to nonimmunological causes in a nonselected patient population receiving leukodepleted transfusions.

Adolescent↗

PubMed1994

Case report: fatal Staphylococcus aureus sepsis from single-donor platelet transfusion.

Bacterial sepsis is a rare and potentially fatal complication of platelet transfusions. Bacterial contamination is estimated to occur in 2% to 6% of platelet concentrates, but clinically apparent septicemia occurs in less than 1% of multi-donor platelet transfusions. The incidence of bacterial sepsis from single-donor platelet transfusions is significantly lower, possibly because of shorter storage time of apheresis platelets. The authors report a case of fatal Staphylococcus aureus sepsis from a single-donor platelet transfusion obtained through a closed system. They conclude that as the demand for platelet transfusion increases, recognition of bacterial sepsis from transfusions and continued reassessment of procedures for collection and storage of platelet concentrates is warranted.

Aged↗

PubMed2006

A therapeutic platelet transfusion strategy is safe and feasible in patients after autologous peripheral blood stem cell transplantation.

Prophylactic platelet transfusions are considered as standard in most hematology centers, but there is a long-standing controversy as to whether standard prophylactic platelet transfusions are necessary or whether this strategy could be replaced by a therapeutic transfusion strategy. In 106 consecutive cases of patients receiving 140 autologous peripheral blood stem cell transplantations, we used a therapeutic platelet transfusion protocol when patients were in a clinically stable condition. Platelet transfusions were only used when relevant bleeding occurred (more than petechial). Median duration of thrombocytopenia <20 x 10(9)/l and <10 x 10(9)/l was 6 and 3 days, which resulted in a total of 989 and 508 days, respectively. In only 26 out of 140 transplants (19%), we observed clinically relevant bleeding of minor or moderate severity. No severe or life-threatening bleeding was registered. The median and mean number of single donor platelet transfusions was one per transplant (range 0-18). One-third of all transplants, and 47% after high-dose melphalan could be performed without any platelet transfusion. Compared with a historical control group, we could reduce the number of platelet transfusions by one half. This therapeutic platelet transfusion strategy can be performed safely resulting in a considerable reduction in prophylactic platelet transfusions.

Adolescent↗

PubMed2005

Platelet transfusion prophylaxis for patients with haematological malignancies: where to now?

National guidelines for platelet transfusion in many countries recommend that the general platelet transfusion trigger for prophylaxis is 10x10(9)/l. This annotation reviews the evidence for this threshold level and discusses other current unresolved issues relevant to platelet transfusion practice such as the optimal dose and the clinical benefit of a strategy for the prophylactic use of platelet transfusions when the platelet count falls below a given threshold.

Guideline Adherence↗