Medicine:Platelet transfusion

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Short description: Treatment for bleeding irregularities
Platelet transfusion
Platelet blood bag.jpg
A bag of platelets
Clinical data
Other namesPlatelet concentrate, platelet component
ATC code
Identifiers
ChemSpider
  • none

Platelet transfusion, also known as platelet concentrate, is used to prevent or treat bleeding in people with either a low platelet count or poor platelet function.[1] Often this occurs in people receiving cancer chemotherapy.[1] Preventive transfusion is often done in those with platelet levels of less than 10 x 109/L.[2] In those who are bleeding transfusion is usually carried out at less than 50 x 109/L.[2] Blood group matching (ABO, RhD) is typically recommended before platelets are given.[2] Unmatched platelets, however, are often used due to the unavailability of matched platelets.[3] They are given by injection into a vein.[4]

Side effects can include allergic reactions such as anaphylaxis, infection, and lung injury.[2] Bacterial infections are relatively more common with platelets as they are stored at warmer temperatures.[2] Platelets can be produced either from whole blood or by apheresis.[1] They keep for up to five to seven days.[1]

Platelet transfusions came into medical use in the 1950s and 1960s.[1][5] It is on the World Health Organization's List of Essential Medicines.[6][7] Some versions of platelets have had the white blood cells partially removed or been gamma irradiated which have specific benefits for certain populations.[8]

Medication use

Prevention of bleeding

International guidelines recommend that platelets transfusions are given to people with reversible bone marrow failure to reduce the risk of spontaneous bleeding when the platelet count is less than 10 x 109/L.[9][10][11][12][13] If the person is well using a higher platelet count threshold does not reduce the risk of bleeding further.[14]

Prevention versus treatment of bleeding

A review in people with blood cancers receiving intensive chemotherapy or a stem cell transplant found that overall giving platelet transfusions when the platelet count is less than 10 x 109/L reduced the number of bleeding events and days with significant bleeding.[15] However, this benefit was only seen in certain patient groups, and people undergoing an autologous stem cell transplant derived no obvious benefit.[15] Despite prophylactic platelet transfusions, people with blood cancers often bleed, and other risk factors for bleeding such as inflammation and duration of thrombocytopenia should be considered.[13]

There is little evidence for the use of preventive platelet transfusions in people with chronic bone marrow failure, such as myelodysplasia or aplastic anemia.[16] Multiple guidelines recommend prophylactic platelet transfusions are not used routinely in people with chronic bone marrow failure, and instead an individualised approach should be taken.[11][10][13]

Several studies have now assessed the benefit of using preventive platelet transfusions in adults with dengue who have profound thrombocytopenia (platelet count < 20 x 109/L.[17] There is no evidence that this reduce the risk of bleeding, but there is evidence that they increase the risk of harm due to the platelet transfusion (increased risk of a transfusion reaction including anaphylaxis).[17]

Platelet transfusion threshold

Two reviews in people with blood cancers receiving intensive chemotherapy or a stem cell transplant found that overall giving platelet transfusions when the platelet count is less than 10 x 109/L compared to giving platelet transfusions when the platelet count is less than 20 or 30 x 109/L had no effect on the risk of bleeding.[14][18]

Higher platelet transfusion thresholds have been used in premature neonates, but this has been based on limited evidence.[19] There is now evidence that using a high platelet count threshold (50 x 109/L) increases the risk of death or bleeding compared to a lower platelet count threshold (25 x 109/L) in premature neonates.[20]

Dose

A review in people with blood cancers compared different platelet transfusion doses.[21] This review found no difference in the number of people who had clinically significant bleeding between platelet transfusions that contained a small number of platelets (low dose – 1.1 x 1011/m2) and those that contained an intermediate number of platelets (intermediate dose – 2.2 x 1011/m2). This review also found no difference in the number of people who had clinically significant bleeding between platelet transfusions that contained a small number of platelets and those that contained a large number of platelets (high dose – 4.4 x 1011/m2).[21] One of the review's included studies reported on transfusion reactions. This study's authors suggested that a high-dose platelet transfusion strategy may lead to a higher rate of transfusion-related adverse events.[22]

Prior to procedures

In people with a low platelet count, prophylactic platelet transfusions do not need to be given prior to procedures that have a low risk of causing bleeding.[10][13][9] Low-risk procedures include surgical sites that do not contain many blood vessels e.g. cataract surgery,[13] or minor procedures.[10][13] The evidence is very uncertain about the effect of platelet transfusions prior to surgery for people with a low platelet count on the all-cause mortality, the number of participants with bleeding events after surgery, serious surgery-related or transfusion-related adverse events.[23]

Guidelines recommend that it is safe to perform central venous catheter insertion when the platelet count is 20 x 109/L or above.[9][13] The evidence for this is based on observational studies in which bleeding occurred due to procedure error rather than due to the platelet count.[13][24]

Platelet transfusion thresholds for more major procedures are based on expert opinion alone.[25] Guidelines recommend a threshold of 50 x 109/L for major surgery and a threshold of 100 x 109/L for surgery on the brain or the back of the eye.[10][13][11]

Treatment of bleeding

There is little evidence for the effectiveness of platelet transfusions or the optimal dose when a person with a low platelet count is actively bleeding. Current recommendations are based on consensus guidelines from around the world.[10][9]

Side effects

Side effects can include allergic reactions such as anaphylaxis, infection, and lung injury.[2] Bacterial infections are relatively more common with platelets as they are stored at warmer temperatures.[2]

Usage

People with hematological disorders or cancer receive the largest proportion of platelet transfusions.[26][27][28] Most are given to prevent bleeding during treatment with chemotherapy or stem cell transplant.[28][27][29] Much of the remainder are used in general medicine, cardiac surgery and in intensive care.[28][27][29]

Unlike other blood products demand for platelet transfusions appears to be increasing in several countries around the world.[26] An ageing population, an increase in the number of people with blood cancer, and changes to the management of these cancers are likely the major reasons for the rise in demand for platelets.[26] Since 1990, the number of stem cell transplants performed in Europe has risen from 4,200 to over 40,000 annually.[30]

History

Platelet transfusions came into medical use in the 1950s and 1960s.[1] It is on the World Health Organization's List of Essential Medicines.[6]

Society and culture

In the United Kingdom it costs the NHS about 200 pounds per unit.[31]

Manufacture

Platelets can be produced either from whole blood donations or by apheresis.[1] They keep for up to five to seven days.[1]

Platelet components can have had the white blood cells partially removed (leucodepleted) which decreases the risk of having a transfusion reaction.[32] They can be treated with ultraviolet light which decreases the risk of transmission of certain infections.[33] They can be gamma irradiated which have specific benefits for certain populations (those at risk of transfusion-associated graft versus host disease).[8]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Hillyer, Christopher D. (2007) (in en). Blood Banking and Transfusion Medicine: Basic Principles & Practice. Elsevier Health Sciences. pp. 308–310. ISBN 978-0443069819. https://books.google.com/books?id=3QwXx_enKbcC&pg=PT329. 
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 "Transfusion Medicine". Primary Care 43 (4): 651–659. December 2016. doi:10.1016/j.pop.2016.07.004. PMID 27866583. 
  3. "ABO-mismatched platelet transfusions: strategies to mitigate patient exposure to naturally occurring hemolytic antibodies" (in English). Transfusion and Apheresis Science 42 (1): 83–8. February 2010. doi:10.1016/j.transci.2009.10.013. PMID 20034854. 
  4. Linton, Adrianne Dill (2015). Introduction to Medical-Surgical Nursing. Elsevier Health Sciences. p. 287. ISBN 9781455776412. https://books.google.com/books?id=mi3uBgAAQBAJ&pg=PA287. 
  5. (in en) Supportive therapy in haematology. Springer Science & Business Media. 2012. p. 190. ISBN 9781461325772. https://books.google.com/books?id=waSZBwAAQBAJ&pg=PA190. 
  6. 6.0 6.1 World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. 2019. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO. 
  7. World Health Organization model list of essential medicines: 22nd list (2021). Geneva: World Health Organization. 2021. WHO/MHP/HPS/EML/2021.02. 
  8. 8.0 8.1 Hillyer, Christopher D. (2007) (in en). Blood Banking and Transfusion clinical Basic Principles & Practice. Elsevier Health Sciences. p. 320. ISBN 978-0443069819. https://books.google.com/books?id=3QwXx_enKbcC&q=irradiated%20platelets&pg=PT341. 
  9. 9.0 9.1 9.2 9.3 "Platelet transfusion: a clinical practice guideline from the AABB". Annals of Internal Medicine 162 (3): 205–13. February 2015. doi:10.7326/M14-1589. PMID 25383671. 
  10. 10.0 10.1 10.2 10.3 10.4 10.5 "Blood transfusion | Guidance and guidelines | NICE". https://www.nice.org.uk/guidance/ng24. 
  11. 11.0 11.1 11.2 "Patient Blood Management Guidelines | National Blood Authority". http://www.blood.gov.au/pbm-guidelines. 
  12. "Platelet Transfusion for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update". Journal of Clinical Oncology 36 (3): 283–299. January 2018. doi:10.1200/jco.2017.76.1734. PMID 29182495. 
  13. 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 "Guidelines for the use of platelet transfusions". British Journal of Haematology 176 (3): 365–394. February 2017. doi:10.1111/bjh.14423. PMID 28009056. https://research-information.bris.ac.uk/en/publications/guidelines-for-the-use-of-platelet-transfusions(2061ef98-4b14-4dbf-ac06-3e1b75bc804f).html. 
  14. 14.0 14.1 "Comparison of different platelet count thresholds to guide administration of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation". The Cochrane Database of Systematic Reviews 2015 (11): CD010983. November 2015. doi:10.1002/14651858.cd010983.pub2. PMID 26576687. 
  15. 15.0 15.1 "A therapeutic-only versus prophylactic platelet transfusion strategy for preventing bleeding in patients with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation". The Cochrane Database of Systematic Reviews 9 (9): CD010981. September 2015. doi:10.1002/14651858.CD010981.pub2. PMID 26422767. 
  16. "Comparison of a therapeutic-only versus prophylactic platelet transfusion policy for people with congenital or acquired bone marrow failure disorders". The Cochrane Database of Systematic Reviews 2018 (5): CD012342. May 2018. doi:10.1002/14651858.cd012342.pub2. PMID 29758592. 
  17. 17.0 17.1 "Time to stop prophylactic platelet transfusion for adult dengue". Lancet 389 (10079): 1583–1584. April 2017. doi:10.1016/s0140-6736(17)30545-7. PMID 28283287. 
  18. Cochrane Haematological Malignancies Group, ed (May 2012). "Prophylactic platelet transfusion for prevention of bleeding in patients with haematological disorders after chemotherapy and stem cell transplantation". The Cochrane Database of Systematic Reviews (5): CD004269. doi:10.1002/14651858.CD004269.pub3. PMID 22592695. 
  19. "Guidelines on transfusion for fetuses, neonates and older children". British Journal of Haematology 175 (5): 784–828. December 2016. doi:10.1111/bjh.14233. PMID 27861734. https://semanticscholar.org/paper/7b87a1815816402c4460689ef1abc48fb83f2758. 
  20. "Randomized Trial of Platelet-Transfusion Thresholds in Neonates". The New England Journal of Medicine 380 (3): 242–251. January 2019. doi:10.1056/nejmoa1807320. PMID 30387697. 
  21. 21.0 21.1 "Different doses of prophylactic platelet transfusion for preventing bleeding in people with haematological disorders after myelosuppressive chemotherapy or stem cell transplantation". The Cochrane Database of Systematic Reviews 2015 (10): CD010984. October 2015. doi:10.1002/14651858.CD010984.pub2. PMID 26505729. 
  22. "Transfusion-related adverse events in the Platelet Dose study". Transfusion 55 (1): 144–53. January 2015. doi:10.1111/trf.12791. PMID 25065959. 
  23. Cochrane Haematological Malignancies Group, ed (April 2018). "Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia". The Cochrane Database of Systematic Reviews 4: CD011980. doi:10.1002/14651858.CD011980.pub3. PMID 29709077. 
  24. "Comparison of different platelet transfusion thresholds prior to insertion of central lines in patients with thrombocytopenia". The Cochrane Database of Systematic Reviews (12): CD011771. December 2015. doi:10.1002/14651858.cd011771.pub2. PMID 26627708. 
  25. "Prophylactic platelet transfusions prior to surgery for people with a low platelet count". The Cochrane Database of Systematic Reviews 9: CD012779. September 2018. doi:10.1002/14651858.cd012779.pub2. PMID 30221749. 
  26. 26.0 26.1 26.2 "Why has demand for platelet components increased? A review". Transfusion Medicine 24 (5): 260–8. October 2014. doi:10.1111/tme.12155. PMID 25327286. https://ora.ox.ac.uk/objects/uuid:a82e8565-8661-4f45-95b2-ec3ccc59c54f. 
  27. 27.0 27.1 27.2 "Where did platelets go in 2012? A survey of platelet transfusion practice in the North of England". Transfusion Medicine 24 (4): 213–8. August 2014. doi:10.1111/tme.12126. PMID 24957661. 
  28. 28.0 28.1 28.2 "Evaluation of platelet transfusion triggers in a tertiary-care hospital". Transfusion 47 (2): 206–11. February 2007. doi:10.1111/j.1537-2995.2007.01090.x. PMID 17302765. 
  29. 29.0 29.1 Whitaker, Barbee I; Rajbhandary, Srijana; Harris, Angela (2015). The 2013 AABB Blood Collection, Utilization, and Patient Blood Management Survey Report. AABB. http://www.aabb.org/research/hemovigilance/bloodsurvey/Pages/default.aspx. 
  30. "Is the use of unrelated donor transplantation leveling off in Europe? The 2016 European Society for Blood and Marrow Transplant activity survey report". Bone Marrow Transplantation 53 (9): 1139–1148. September 2018. doi:10.1038/s41409-018-0153-1. PMID 29540849. 
  31. Yentis, Steven M.; Hirsch, Nicholas P.; Ip, James (2013) (in en). Anaesthesia and Intensive Care A–Z: An Encyclopedia of Principles and Practice. Elsevier Health Sciences. p. 147. ISBN 9780702053757. https://books.google.com/books?id=Te7TAAAAQBAJ&pg=PA147. 
  32. "FAQ: Leucodepletion of red cells and platelets". 14 December 2015. https://transfusion.com.au/blood_products/components/leucodepletion. 
  33. "Pathogen-reduced platelets for the prevention of bleeding". The Cochrane Database of Systematic Reviews 7: CD009072. July 2017. doi:10.1002/14651858.CD009072.pub3. PMID 28756627. 

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