Platelet transfusion

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Platelet transfusion
Platelet blood bag.jpg
A bag of platelets
Clinical data
Other namesPlatelet concentrate, platelet component
ATC code
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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]

Contents

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]

Related Research Articles

<span class="mw-page-title-main">Chemotherapy</span> Treatment of cancer using drugs that inhibit cell division or kill cells

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent or it may aim to prolong life or to reduce symptoms. Chemotherapy is one of the major categories of the medical discipline specifically devoted to pharmacotherapy for cancer, which is called medical oncology.

<span class="mw-page-title-main">Non-Hodgkin lymphoma</span> Type of cancer of lymph nodes

Non-Hodgkin lymphoma (NHL), also known as non-Hodgkin's lymphoma, is a group of blood cancers that includes all types of lymphomas except Hodgkin lymphomas. Symptoms include enlarged lymph nodes, fever, night sweats, weight loss, and tiredness. Other symptoms may include bone pain, chest pain, or itchiness. Some forms are slow-growing while others are fast-growing.

<span class="mw-page-title-main">Lymphoma</span> Hematologic cancer that affects lymphocytes

Lymphoma is a group of blood and lymph tumors that develop from lymphocytes. The name typically refers to just the cancerous versions rather than all such tumours. Signs and symptoms may include enlarged lymph nodes, fever, drenching sweats, unintended weight loss, itching, and constantly feeling tired. The enlarged lymph nodes are usually painless. The sweats are most common at night.

<span class="mw-page-title-main">Myelodysplastic syndrome</span> Diverse collection of blood-related cancers

A myelodysplastic syndrome (MDS) is one of a group of cancers in which immature blood cells in the bone marrow do not mature, and as a result, do not develop into healthy blood cells. Early on, no symptoms typically are seen. Later, symptoms may include fatigue, shortness of breath, bleeding disorders, anemia, or frequent infections. Some types may develop into acute myeloid leukemia.

<span class="mw-page-title-main">Thalassemia</span> Family of inherited blood disorders

Thalassemias are inherited blood disorders that result in abnormal hemoglobin. Symptoms depend on the type of thalassemia and can vary from none to severe. Often there is mild to severe anemia as thalassemia can affect the production of red blood cells and also affect how long the red blood cells live. Symptoms of anemia include feeling tired and having pale skin. Other symptoms of thalassemia include bone problems, an enlarged spleen, yellowish skin, pulmonary hypertension, and dark urine. Slow growth may occur in children. Symptoms and presentations of thalassemia can change over time.

<span class="mw-page-title-main">Multiple myeloma</span> Cancer of plasma cells

Multiple myeloma (MM), also known as plasma cell myeloma and simply myeloma, is a cancer of plasma cells, a type of white blood cell that normally produces antibodies. Often, no symptoms are noticed initially. As it progresses, bone pain, anemia, kidney dysfunction, and infections may occur. Complications may include hypercalcemia and amyloidosis.

<span class="mw-page-title-main">Thrombocytopenia</span> Abnormally low levels of platelets in the blood

In hematology, thrombocytopenia is a condition characterized by abnormally low levels of platelets in the blood. Low levels of platelets in turn may lead to prolonged or excessive bleeding. It is the most common coagulation disorder among intensive care patients and is seen in a fifth of medical patients and a third of surgical patients.

<span class="mw-page-title-main">Granulocyte</span> Category of white blood cells

Granulocytes are cells in the innate immune system characterized by the presence of specific granules in their cytoplasm. Such granules distinguish them from the various agranulocytes. All myeloblastic granulocytes are polymorphonuclear, that is, they have varying shapes (morphology) of the nucleus ; and are referred to as polymorphonuclear leukocytes. In common terms, polymorphonuclear granulocyte refers specifically to "neutrophil granulocytes", the most abundant of the granulocytes; the other types have varying morphology. Granulocytes are produced via granulopoiesis in the bone marrow.

<span class="mw-page-title-main">Acute lymphoblastic leukemia</span> Blood cancer characterised by overproduction of lymphoblasts

Acute lymphoblastic leukemia (ALL) is a cancer of the lymphoid line of blood cells characterized by the development of large numbers of immature lymphocytes. Symptoms may include feeling tired, pale skin color, fever, easy bleeding or bruising, enlarged lymph nodes, or bone pain. As an acute leukemia, ALL progresses rapidly and is typically fatal within weeks or months if left untreated.

<span class="mw-page-title-main">Gastrointestinal bleeding</span> Medical condition

Gastrointestinal bleeding, also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-deficiency anemia resulting in feeling tired or heart-related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present.

<span class="mw-page-title-main">Plateletpheresis</span> Method of collecting platelets from blood

Plateletpheresis is the process of collecting thrombocytes, more commonly called platelets, a component of blood involved in blood clotting. The term specifically refers to the method of collecting the platelets, which is performed by a device used in blood donation that separates the platelets and returns other portions of the blood to the donor. Platelet transfusion can be a life-saving procedure in preventing or treating serious complications from bleeding and hemorrhage in patients who have disorders manifesting as thrombocytopenia or platelet dysfunction. This process may also be used therapeutically to treat disorders resulting in extraordinarily high platelet counts such as essential thrombocytosis.

<span class="mw-page-title-main">Tranexamic acid</span> Chemical compound

Tranexamic acid (TXA) is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken either orally or by injection into a vein.

<span class="mw-page-title-main">Fresh frozen plasma</span> Liquid portion of whole blood

Fresh frozen plasma (FFP) is a blood product made from the liquid portion of whole blood. It is used to treat conditions in which there are low blood clotting factors or low levels of other blood proteins. It may also be used as the replacement fluid in plasma exchange. Using ABO compatible plasma, while not required, may be recommended. Use as a volume expander is not recommended. It is administered by slow injection into a vein.

<span class="mw-page-title-main">Packed red blood cells</span> Red blood cells separated for blood transfusion

Packed red blood cells, also known as packed cells, are red blood cells that have been separated for blood transfusion. The packed cells are typically used in anemia that is either causing symptoms or when the hemoglobin is less than usually 70–80 g/L. In adults, one unit brings up hemoglobin levels by about 10 g/L. Repeated transfusions may be required in people receiving cancer chemotherapy or who have hemoglobin disorders. Cross-matching is typically required before the blood is given. It is given by injection into a vein.

Platelet transfusion refractoriness is the repeated failure to achieve the desired level of blood platelets in a patient following a platelet transfusion. The cause of refractoriness may be either immune or non-immune. Among immune-related refractoriness, antibodies against HLA antigens are the primary cause. Non-immune causes include splenomegaly, fever, and sepsis.

Patient Blood Management (PBM) is a set of medical practices designed to optimise the care of patients who might need a blood transfusion. Patient blood management programs use an organized framework to improve blood health, thus increasing patient safety and quality of life, reducing costs, and improving clinical outcomes. Some strategies to accomplish this include ensuring that anemia is treated prior to a surgical operation, using surgical techniques that limit blood loss, and returning blood lost during surgery to the patient via intraoperative blood salvage.

<span class="mw-page-title-main">Hodgkin lymphoma</span> Type of blood and immune-system cancer

Hodgkin lymphoma (HL) is a type of lymphoma in which cancer originates from a specific type of white blood cell called lymphocytes, where multinucleated Reed–Sternberg cells are present in the patient's lymph nodes. The condition was named after the English physician Thomas Hodgkin, who first described it in 1832. Symptoms may include fever, night sweats, and weight loss. Often, nonpainful enlarged lymph nodes occur in the neck, under the arm, or in the groin. Persons affected may feel tired or be itchy.

Red blood cells (erythrocytes) from donors contain normal hemoglobin (HbA), and transfusion of normal red blood cells into people with sickle cell disease reduces the percentage of red cells in the circulation containing the abnormal hemoglobin (HbS). Although transfusion of donor red blood cells can ameliorate and even prevent complications of sickle cell disease in certain circumstances, transfusion therapy is not universally beneficial in sickle cell disease.

Neonates are defined as babies up to 28 days after birth. Most extremely preterm babies require at least one red cell transfusion; this is partly due to the amount of blood removed with blood samples compared to the baby's total blood volume and partly due to anemia of prematurity. Most transfusions are given as small volume top-up transfusions to increase the baby's hemoglobin above a certain pre-defined level, or because the baby is unwell due to the anemia. Possible side-effects of anemia in babies can be poor growth, lethargy and episodes of apnea. Exchange blood transfusion is used to treat a rapidly rising bilirubin that does not respond to treatment with phototherapy or intravenous immunoglobulin. This is usually due to hemolytic disease of the newborn, but may also be due to other causes, e.g., G6PD deficiency.

A granulocyte transfusion is a medical procedure in which granulocytes are infused into a person's blood. Granulocyte transfusions were historically used to prevent and treat infections in people with neutropenia, but the practice declined in popularity in the 1980s. Interest in the procedure increased in the 1990s due to the development of more effective methods for harvesting granulocytes and a growing population of people with severe neutropenia from chemotherapy. However, the treatment's efficacy remains poorly understood and its use is controversial.

References

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  3. ↑ Josephson CD, Castillejo MI, Grima K, Hillyer CD (February 2010). "ABO-mismatched platelet transfusions: strategies to mitigate patient exposure to naturally occurring hemolytic antibodies". Transfusion and Apheresis Science. 42 (1): 83–88. doi:10.1016/j.transci.2009.10.013. PMID   20034854.
  4. ↑ Flagg C (2015). "Intravenous Therapy". In Linton AD (ed.). Introduction to Medical-Surgical Nursing. Elsevier Health Sciences. p. 287. ISBN   978-1455776412. Archived from the original on 2017-01-12.
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  14. 1 2 Estcourt LJ, Stanworth SJ, Doree C, Hopewell S, Trivella M, Murphy MF (November 2015). "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. doi:10.1002/14651858.cd010983.pub2. PMC   4717525 . PMID   26576687.
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  16. ↑ Malouf R, Ashraf A, Hadjinicolaou AV, Doree C, Hopewell S, Estcourt LJ (May 2018). "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. doi:10.1002/14651858.cd012342.pub2. PMC   5985156 . PMID   29758592.
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  18. ↑ Estcourt L, Stanworth S, Doree C, Hopewell S, Murphy MF, Tinmouth A, Heddle N, et al. (Cochrane Haematological Malignancies Group) (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. ↑ New HV, Berryman J, Bolton-Maggs PH, Cantwell C, Chalmers EA, Davies T, et al. (December 2016). "Guidelines on transfusion for fetuses, neonates and older children". British Journal of Haematology. 175 (5): 784–828. doi: 10.1111/bjh.14233 . PMID   27861734. S2CID   3360807.
  20. ↑ Curley A, Stanworth SJ, Willoughby K, Fustolo-Gunnink SF, Venkatesh V, Hudson C, et al. (January 2019). "Randomized Trial of Platelet-Transfusion Thresholds in Neonates". The New England Journal of Medicine. 380 (3): 242–251. doi: 10.1056/nejmoa1807320 . PMID   30387697.
  21. 1 2 Estcourt LJ, Stanworth S, Doree C, Trivella M, Hopewell S, Blanco P, Murphy MF (October 2015). "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. doi:10.1002/14651858.CD010984.pub2. PMC   4724938 . PMID   26505729.
  22. ↑ Kaufman RM, Assmann SF, Triulzi DJ, Strauss RG, Ness P, Granger S, Slichter SJ (January 2015). "Transfusion-related adverse events in the Platelet Dose study". Transfusion. 55 (1): 144–153. doi:10.1111/trf.12791. PMC   4293226 . PMID   25065959.
  23. ↑ Estcourt LJ, Malouf R, Hopewell S, Doree C, Van Veen J, et al. (Cochrane Haematological Malignancies Group) (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. 2018 (4): CD011980. doi:10.1002/14651858.CD011980.pub3. PMC   5957267 . PMID   29709077.
  24. ↑ Estcourt LJ, Desborough M, Hopewell S, Doree C, Stanworth SJ (December 2015). "Comparison of different platelet transfusion thresholds prior to insertion of central lines in patients with thrombocytopenia". The Cochrane Database of Systematic Reviews. 2015 (12): CD011771. doi:10.1002/14651858.cd011771.pub2. PMC   4755335 . PMID   26627708.
  25. ↑ Estcourt LJ, Malouf R, Doree C, Trivella M, Hopewell S, Birchall J (September 2018). "Prophylactic platelet transfusions prior to surgery for people with a low platelet count". The Cochrane Database of Systematic Reviews. 2018 (9): CD012779. doi:10.1002/14651858.cd012779.pub2. PMC   5687560 . PMID   30221749.
  26. 1 2 3 Estcourt LJ (October 2014). "Why has demand for platelet components increased? A review". Transfusion Medicine. 24 (5): 260–268. doi:10.1111/tme.12155. PMID   25327286. S2CID   10698976.
  27. 1 2 3 Charlton A, Wallis J, Robertson J, Watson D, Iqbal A, Tinegate H (August 2014). "Where did platelets go in 2012? A survey of platelet transfusion practice in the North of England". Transfusion Medicine. 24 (4): 213–218. doi:10.1111/tme.12126. PMID   24957661. S2CID   2537906.
  28. 1 2 3 Cameron B, Rock G, Olberg B, Neurath D (February 2007). "Evaluation of platelet transfusion triggers in a tertiary-care hospital". Transfusion. 47 (2): 206–211. doi:10.1111/j.1537-2995.2007.01090.x. PMID   17302765. S2CID   36811397.
  29. 1 2 Whitaker BI, Rajbhandary S, Harris A (2015). The 2013 AABB Blood Collection, Utilization, and Patient Blood Management Survey Report. AABB. Archived from the original on 2016-01-26.
  30. ↑ Passweg JR, Baldomero H, Bader P, Basak GW, Bonini C, Duarte R, et al. (September 2018). "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. doi:10.1038/s41409-018-0153-1. PMC   6128821 . PMID   29540849.
  31. ↑ Yentis SM, Hirsch NP, Ip J (2013). Anaesthesia and Intensive Care A–Z: An Encyclopedia of Principles and Practice. Elsevier Health Sciences. p. 147. ISBN   978-0702053757. Archived from the original on 2017-01-12.
  32. ↑ "FAQ: Leucodepletion of red cells and platelets". transfusion.com.au. 14 December 2015. Archived from the original on 13 July 2017. Retrieved 18 July 2017.
  33. ↑ Estcourt LJ, Malouf R, Hopewell S, Trivella M, Doree C, Stanworth SJ, Murphy MF (July 2017). "Pathogen-reduced platelets for the prevention of bleeding". The Cochrane Database of Systematic Reviews. 7 (7): CD009072. doi:10.1002/14651858.CD009072.pub3. PMC   5558872 . PMID   28756627.
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