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A noninferiority study was performed comparing low-dose and standard-dose prophylactic platelet transfusions. A double-blind randomized controlled trial (RCT) was performed in 6 sites in 3 countries. Thrombocytopenic adults requiring prophylactic platelet transfusion were randomly allocated to standard-dose (300-600 x 10(9) platelets/product) or lo...
Contexts in source publication
Context 1
... patient's chart was also reviewed to capture any documented information related to bleeding in the 24-hour time period prior to the clinical assessment Grading bleeds. Bleeding was categorized using the WHO scale grades 1 to 4. 14 Specific descriptors for each grade of bleeding were developed a priori ( Table 1). ...
Context 2
... well as the late Dr Scott Murphy for his constant support and encouragement throughout the design and implementation phases of this study. Special thanks to the study personnel at each site who participated in recruitment and data collection; the individuals who participated in the adjudication of bleeding events; and the members of the Data Safety Monitoring Board (all groups listed in the Supplemental Appendix, Table 5. Summary information of platelet transfusions per treatment group Characteristic Standard-dose platelet arm, n 61 Low-dose platelet arm, n 58 Mean difference, low dose minus standard dose (95% CI) P Mean (SD) duration of thrombocytopenia, d 14.0 (9.1) 15.8 (9.3) 1.8 (1.5-5.2) .281 ...
Citations
... We defined and graded bleeding according to a modified World Health Organization (WHO) classification [22][23][24][25]. Grade 1 and 2 covers bleedings that do not require red blood cell (RBC) transfusion. ...
Thrombocytopenia (platelet count < 150 × 109/L) is common in intensive care unit (ICU) patients and is likely associated with worse outcomes. In this study we present international contemporary data on thrombocytopenia in ICU patients.
We conducted a prospective cohort study in adult ICU patients in 52 ICUs across 10 countries. We assessed frequencies of thrombocytopenia, use of platelet transfusions and clinical outcomes including mortality. We evaluated pre-selected potential risk factors for the development of thrombocytopenia during ICU stay and associations between thrombocytopenia at ICU admission and 90-day mortality using pre-specified logistic regression analyses.
We analysed 1166 ICU patients; the median age was 63 years and 39.5% were female. Overall, 43.2% (95% confidence interval (CI) 40.4–46.1) had thrombocytopenia; 23.4% (20–26) had thrombocytopenia at ICU admission, and 19.8% (17.6–22.2) developed thrombocytopenia during their ICU stay. Absence of acquired immune deficiency syndrome (AIDS), non-cancer-related immune deficiency, liver failure, male sex, septic shock, and bleeding at ICU admission were associated with the development of thrombocytopenia during ICU stay. Among patients with thrombocytopenia, 22.6% received platelet transfusion(s), and 64.3% of in-ICU transfusions were prophylactic. Patients with thrombocytopenia had higher occurrences of bleeding and death, fewer days alive without the use of life-support, and fewer days alive and out of hospital. Thrombocytopenia at ICU admission was associated with 90-day mortality (adjusted odds ratio 1.7; 95% CI 1.19–2.42).
Thrombocytopenia occurred in 43% of critically ill patients and was associated with worse outcomes including increased mortality. Platelet transfusions were given to 23% of patients with thrombocytopenia and most were prophylactic.
... 22 The World Health Organization (WHO) bleeding scale or the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) is often used. [23][24][25] They are well-established in clinical practice and familiar to most physicians, including nonhematological specialists. ICH is a fatal complication of this pathology. ...
Intracerebral hemorrhage (ICH) is a rare and fatal complication of immune thrombocytopenia. ICH is more common in children than in the adult population. A 30-year-old male patient, a known case of immune thrombocytopenia, presented with sudden onset severe headache and vomiting. Computed tomography scan showed a large right frontal intracerebral hematoma. His platelet counts were low, and he received multiple transfusions. Though he was initially conscious, his neurological condition progressively deteriorated, so the decision was taken for an emergency craniotomy. Despite multiple transfusions, his platelet counts were 10,000/µL, so craniotomy was very risky. He underwent an emergency splenectomy and received one unit of single donor platelets. Subsequently, his platelets count increased a few hours after, and he underwent successful evacuation of intracerebral hematoma. He eventually had an excellent neurological outcome. Though intracranial hemorrhage carries significant morbidity and mortality, a timely decision of emergency splenectomy followed by craniotomy can result in an excellent clinical outcome.
... 43% case of all the hemorrhagic manifestations occurred in patients with severe thrombocytopenia 5 3 with platelet count <0.5x10 /mm .48% patients who had platelet count 5 5 3 happened in patients with platelet count<10x10 /mm and least bleeding manifestation happened in patients with platelet count is 5 3. >40x10 /mm 30 patients who had Hb <7.0 g/dl received packed red cells (PRC) along with platelet transfusion .The patient who received multiple platelet transfusions showed post transfusion platelet 5 3 increment of >0.5x10 /mm from each units. There is signicant increase in platelet count and resolution of bleeding complications on each platelet unit transfusion. ...
... Makroo et (26) al found 0.8% mortality rate but in the present study the high rate 10% may be due to severe bleeding from rectum. Published data from (5,6) various institutions and countries have put varying gures as the trigger for platelet transfusion in hospitalized dengue patients. In this 5 3 study 13% patients who had platelet count <0.5x10 /mm and 35% 5 3 patients whose platelet count was between 0.5-10x10 /mm received multiple platelet transfusions, and whose platelet count was 5 3 >40x10 /mm received single unit of platelet transfusion. ...
Introduction: Dengue fever and dengue hemorrhagic fever (1) are usually a benign condition caused by an arthropod borne virus and bleeding is one of the dreaded complications associated with higher mortality in DHF/DSS (1) Dysfunction of platelets are Prothrombotic complications associated with severe cases of dengue. Thus, platelets could be considered cells that are active against the anti DENV immune response. Platelet transfusion is given in those patients who are either bleeding or having other hemorrhagic symptoms along with thrombocytopenia. AProspective study was conducted of 100 dengue positive patients with bleeding tendency in department of pathology, Government medical college and Sir. T. Hospital, Bhavnagar, Gujarat during period of July 2020 to MAY 2021.The patient who received multiple platelet transfusions showed post transfusion platelet increment of >0.5x105/mm3 from each unit
... In particular, PLT orders above Another potential area for improvement in appropriateness represents a high ratio (32 %) of inappropriate double units PLT transfusions despite the solid evidence that single unit PLT transfusions are both effective and inventory-sparing. A systematic review by the Cochrane collaboration included six randomized controlled trials (RCTs) [34][35][36][37][38][39] that compared different platelet transfusion doses and did not find evidence of a difference in the risk of bleeding between low dose (1.1 Â 10 11 /m 2 ) and standard dose (2.2 Â 10 11 /m2) as well as between standard dose and high dose platelet transfusions (4.4 Â 10 11 /m2) [40]. The most common reason for double dose PLT orders was planned procedure and bleeding, yet even 15.9% of prophylactic transfusions due to low PLT count were double dose. ...
Background
Hematology patients are intensive platelet users. In clinical practice, a substantial proportion of platelet (PLT) transfusions are routinely administered outside the guidelines despite compelling evidence for recommendations. Those unnecessary PLT transfusions are an unjustified extra burden on a scarce healthcare resource and may also be detrimental to the patients. This study aims to evaluate indications and assess the appropriateness of PLT transfusion, as well as to identify common discrepancies and propose modalities for better compliance with guidelines.
Material and methods
The audit of all PLT orders for adult hematological inpatients was conducted over 2 months. The assessment was performed using guidelines for PLT transfusion. Patient demographic, clinical, and transfusion data were collected from hospital electronic medical records.
Results
Based on 286 PLT orders, 344 PCs were transfused to 67 patients: 235 (82.2%) prophylactical due to low PLT count, 34 (11.9%) preprocedural and 17 (5.9%) therapeutic. Overall, 105 (36.77%) PLT transfusions were inappropriate: 78 (33.2%) of all prophylactic PLT transfusions due to low PLT count, 17 (50%) off all preprocedural and 10 (58.8%) of all therapeutical transfusion. The major reason for PLT transfusion inappropriateness was transfusion above the recommended threshold. Double units of PCs were transfused in 36.7% of all PLT transfusions and 32.4% of them were considered inappropriate.
Conclusion
Our audit of PLT transfusion practice found a large proportion of inappropriate PLT transfusions. Based on the most common deviations from the guidelines a variety of targeted measures for improvement are proposed.
... 7 Balitsky and colleagues present a detailed analysis of bleeding assessments from three randomized controlled trials (RCTs) to describe the frequency of the different signs and symptoms of WHO Grade 1 and 2 bleeding events, and to examine associations with more severe (Grade 3 and 4) bleeding. 8 The data had been prospectively collected during a trial of RBC transfusion thresholds, 9 the Strategies for Transfusion of Platelets (SToP) trial, 10 and the Pathogen Reduction Evaluation and Predictive Analytical Rating Score (PREPAReS) trial, 11 and comprised 315 adults with thrombocytopenia secondary to hematologic malignancy or chemotherapy who had sufficient baseline data and at least one daily bleeding assessment. The majority (>90%) of patients were being treated for acute leukemia, mostly acute myeloid leukemia. ...
... However, the evidence to support these procedure-specific transfusion triggers remains relatively weak [41]. To conserve platelet units, studies have evaluated the safety and efficacy of using platelet transfusion therapeutically (only given to treat active bleeding) rather than prophylactically [43,44], as well as reduced platelet doses in select patient populations [45,46]. While more studies are needed, future guidelines may be adjusted for smaller and less frequent platelet transfusion doses. ...
Purpose of review:
In this review, we discuss current clinical guidelines and potential underlying mechanisms regarding platelet transfusion therapy in patients at risk of bleeding, comparing management of patients with thrombocytopenia versus those with qualitative platelet disorders.
Recent findings:
Platelet transfusion therapy is highly effective in managing bleeding in patients with hypoproliferative thrombocytopenia. Clinical trials have demonstrated that platelet transfusion can be used at a lower trigger threshold and reduced platelet doses, and may be used therapeutically rather than prophylactically in some situations, although additional data are needed. In patients with inherited platelet disorders such as Glanzmann's Thrombasthenia or those with RASGRP2 mutations, platelet transfusion may be ineffective because of competition between transfused and endogenous platelets at the site of vascular injury. Successful management of these patients may require transfusion of additional platelet units, or mechanism-driven combination therapy with other pro-hemostatic agents. In patients on antiplatelet therapy, timing of transfusion and inhibitor mechanism-of-action are key in determining therapeutic success.
Summary:
Expanding our understanding of the mechanisms by which transfused platelets exert their pro-hemostatic function in various bleeding disorders will improve the appropriate use of platelet transfusion.
... Over 40% of patients with thrombocytopenia due to haematological malignancy and intensive chemotherapy encounter one or more bleeding episodes in a broad range of platelet counts, despite trigger-based preventive platelet transfusion practices (Heddle et al., 2009;Slichter et al., 2010;Ypma et al., 2012;Stanworth et al., 2013). As the current prophylactic trigger-based platelet transfusion strategy is associated with adverse transfusion events, costs and resource issues (Stanworth et al., 2015a), better strategies to identify patients prone to bleeding are needed. ...
In daily haematological practice, predicting bleeding in thrombocytopenic patients is difficult, and clinicians adhere to transfusion triggers to guide patients through the aplastic phase of chemotherapy. Platelet count is not the only determinant of bleeding and additional mechanisms for impending haemostasis are likely. Beside clot formation, platelets are essential for the maintenance of integrity of vascular beds. We therefore prospectively investigated associations between biomarkers for endothelial damage (urine albumin excretion) and inflammation (C‐reactive protein) and bleeding (WHO grading) in 88 patients with 116 on‐protocol episodes. We found an increase in grade 2 bleeding with a higher urine albumin/creatinine ratio one day after the measurement [odds ratio (OR) 1·24 for every doubling of the ratio, 95% CI 1·05–1·46, P‐value 0·01] and a 29% increase in the odds of grade 2 bleeding for every doubling of serum C‐reactive protein (CRP) (95% CI 1·04–1·60, P‐value 0·02) after correction for morning platelet count. The 24 h post‐transfusion corrected count increment (CCI24) showed a significant association with these biomarkers: increasing urine albumin/creatinine ratio and CRP were associated with lower CCI24. We report two inexpensive and easy‐to‐apply biomarkers that could be useful in designing a prediction model for bleeding risk in thrombocytopenic patients.
... 34 Transfusing less than the recommended volume could lead to increased risk of severe or life-threatening hemorrhage. 35 Additionally, repeated exposure to platelet products puts patients at increased risk for transfusion-related adverse events like infections, transfusion-related acute lung injury, and anaphylaxis. [35][36][37] At our hospital, development of order sets at different times for different services led to the existence of similar order sets that provide recommendations for weight-based pediatric platelet transfusion volume. ...
... 35 Additionally, repeated exposure to platelet products puts patients at increased risk for transfusion-related adverse events like infections, transfusion-related acute lung injury, and anaphylaxis. [35][36][37] At our hospital, development of order sets at different times for different services led to the existence of similar order sets that provide recommendations for weight-based pediatric platelet transfusion volume. Prior studies have shown that CDS can reduce ordering errors for blood products, but that physician noncompliance with recommendations remained high. ...
Background and Objectives Clinical decision support (CDS) and computerized provider order entry have been shown to improve health care quality and safety, but may also generate previously unanticipated errors. We identified multiple CDS tools for platelet transfusion orders. In this study, we sought to evaluate and improve the effectiveness of those CDS tools while creating and testing a framework for future evaluation of other CDS tools.
Methods Using a query of an enterprise data warehouse at a tertiary care pediatric hospital, we conducted a retrospective analysis to assess baseline use and performance of existing CDS for platelet transfusion orders. Our outcome measure was the percentage of platelet undertransfusion ordering errors. Errors were defined as platelet transfusion volumes ordered which were less than the amount recommended by the order set used. We then redesigned our CDS and measured the impact of our intervention prospectively using statistical process control methodology.
Results We identified that 62% of all platelet transfusion orders were placed with one of two order sets (Inpatient Service 1 and Inpatient Service 2). The Inpatient Service 1 order set had a significantly higher occurrence of ordering errors (3.10% compared with 1.20%). After our interventions, platelet transfusion order error occurrence on Inpatient Service 1 decreased from 3.10 to 0.33%.
Conclusion We successfully reduced platelet transfusion ordering errors by redesigning our CDS tools. We suggest that the use of collections of clinical data may help identify patterns in erroneous ordering, which could otherwise go undetected. We have created a framework which can be used to evaluate the effectiveness of other similar CDS tools.
... According to Slichter et al [2], low dose of platelets led to a lesser number of platelets transfused per patient, but an increased number of transfusion events and platelet dosing had no significant effect on the incidence of bleeding in hypo proliferative thrombocytopenia patients. Heddle et al. [3] indicated that a transfusion of low dose resulted in significantly more platelet transfusion episodes but the donor exposures from platelet transfusions were not significantly different in the standard and low dose. Hence, this study was planned to compare the efficacy of low and high dose with the standard dose of single donor apheresis platelet (SDAP) transfusions in terms of platelet transfusion response indicators-Corrected Count Increment (CCI), Percent Platelet Recovery (PPR), their transfusion free interval and bleeding episodes in thrombocytopenic hemato-oncology patients, so as to optimize the use of one of the most precious resource of our blood component inventory. ...
... Bleeding episodes were also noted during the study period in each patient after every dose and graded according to WHO bleeding scale [3]. ...
... Similar observations has been recorded previously in the studies on mathematical model on platelet survival by JK Hersh et al. [5], where authors observed that survival would be decreased at very high platelet concentrations relative to survival at normal concentrations. In the STOP study by Heddle et al. [3] grade 4 bleed was seen in 5.2% of patients receiving the low dose which lead to discontinuation of the study. We did not have any episodes of grade 4 bleed in our study. ...
Introduction:
To determine an optimal platelet dose in thrombocytopenic patients is important for their judicious use. Transfusing platelets in different doses and comparing their post transfusion response can achieve this.
Aim:
To compare the efficacy of low and high dose single donor apheresis platelets (SDAP) with standard dose transfusions in terms of Corrected Count Increment (CCI), Percent Platelet Recovery (PPR) and transfusion free interval.
Method:
It was a prospective case control study done from January 2016 to April 2017. Twenty-eight hemato-oncology patients with CCI ≥5000 at 20-24 hours after standard dose (3 × 1011/unit), received low dose (1.5 × 1011 platelets/unit) and high dose (>4 × 1011 platelets/unit) SDAP. CCI and PPR were calculated after 20 to 24 hours of transfusion. Transfusion free interval and bleeding episodes were also noted. Grading was done according to WHO bleeding scale.
Result:
There was no statistical difference in CCI and PPR when standard dose was compared with low dose (CCI: p = 0.92, PPR: p = 0.89). When standard and high dose was compared, standard dose gave better results than the high dose in terms of CCI (p = 0.006) and PPR (p = 0.008) although the post transfusion increments were comparable (p = 0.938). High dose gave better (p = 0.005) platelet count increments than low dose but CCI (p = 0.04) and PPR (p = 0.05) was significantly less than the low dose. The difference in transfusion free intervals after three doses was not significant. Donor exposure to the patients was significantly (p = 0.000) reduced to 17.5%.
Conclusion:
Possibility of low dose as an alternative to standard dose can be considered in view of comparable platelet response indicators and significantly reduced donor exposure.
... The disadvantage of all these scores is that they are usually time consuming, which limits their application in the busy daily routine. Therefore, the authors recommend using the World Health Organization (WHO) bleeding scale or the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) [41][42][43] (table 3). They are well established in clinical practice and familiar to most physicians including nonhematological specialists. ...
... Bleeding grades according to the WHO and the NCI Common Terminology Criteria for Adverse Events (CTCAE v4.0)[41][42][43] Hemorrhages in other organs with functional impairment (joints, muscles, kidneys, lungs, etc.) Fatal bleeding (in the NCI CTCAE graded as °V) ...
