Platelet transfusion

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]

Platelet transfusion
A bag of platelets
Clinical data
Other namesPlatelet concentrate, platelet component
ATC code
Identifiers
ChemSpider
  • none

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, the safest and most effective medicines needed in a health system.[6] In the United Kingdom it costs the NHS about £200 per unit.[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]

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][23]

Platelet transfusion thresholds for more major procedures are based on expert opinion alone.[24] 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.[25][26][27] Most are given to prevent bleeding during treatment with chemotherapy or stem cell transplant.[27][26][28] Much of the remainder are used in general medicine, cardiac surgery and in intensive care.[27][26][28]

Unlike other blood products demand for platelet transfusions appears to be increasing in several countries around the world.[25] 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.[25] Since 1990, the number of stem cell transplants performed in Europe has risen from 4,200 to over 40,000 annually.[29]

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, the safest and most effective medicines needed in a health system.[6]

Society and culture

In the United Kingdom it costs the NHS about 200 pounds per unit.[7]

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.[30] They can be treated with ultraviolet light which decreases the risk of transmission of certain infections.[31] They can be gamma irradiated which have specific benefits for certain populations (those at risk of transfusion-associated graft versus host disease).[8]

gollark: Clearly we need space mining and nuclear fission power.
gollark: I'm not sure the UK's does, and I live there.
gollark: I mean, the policies relating to COVID-19 are controlled by governments, which presumably should have *some* plan.
gollark: I propose that we all push in the opposite direction to tectonic plate motion.
gollark: Apparently. Or at least home breadmaking, because she did it first and is now... finding it harder to get ingredients.

References
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  2. Connell NT (December 2016). "Transfusion Medicine". Primary Care. 43 (4): 651–659. doi:10.1016/j.pop.2016.07.004. PMID 27866583.
  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): 83–8. doi:10.1016/j.transci.2009.10.013. PMID 20034854.
  4. Linton AD (2015). Introduction to Medical-Surgical Nursing. Elsevier Health Sciences. p. 287. ISBN 9781455776412. Archived from the original on 2017-01-12.
  5. Das PC, Smit-Sibinga CT, Halie MR (2012). Supportive therapy in haematology. Springer Science & Business Media. p. 190. ISBN 9781461325772. Archived from the original on 2017-01-10.
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  17. Khan Assir MZ (April 2017). "Time to stop prophylactic platelet transfusion for adult dengue". Lancet. 389 (10079): 1583–1584. doi:10.1016/s0140-6736(17)30545-7. PMID 28283287.
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  21. 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. 10 (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): 144–53. doi:10.1111/trf.12791. PMC 4293226. PMID 25065959.
  23. 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 (12): CD011771. doi:10.1002/14651858.cd011771.pub2. PMC 4755335. PMID 26627708.
  24. 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. 9: CD012779. doi:10.1002/14651858.cd012779.pub2. PMC 5687560. PMID 30221749.
  25. Estcourt LJ (October 2014). "Why has demand for platelet components increased? A review". Transfusion Medicine. 24 (5): 260–8. doi:10.1111/tme.12155. PMID 25327286.
  26. 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): 213–8. doi:10.1111/tme.12126. PMID 24957661.
  27. Cameron B, Rock G, Olberg B, Neurath D (February 2007). "Evaluation of platelet transfusion triggers in a tertiary-care hospital". Transfusion. 47 (2): 206–11. doi:10.1111/j.1537-2995.2007.01090.x. PMID 17302765.
  28. 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.
  29. 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.
  30. "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.
  31. Estcourt, Lise J.; Malouf, Reem; Hopewell, Sally; Trivella, Marialena; Doree, Carolyn; Stanworth, Simon J.; Murphy, Michael F. (30 July 2017). "Pathogen-reduced platelets for the prevention of bleeding". The Cochrane Database of Systematic Reviews. 7: CD009072. doi:10.1002/14651858.CD009072.pub3. ISSN 1469-493X. PMC 5558872. PMID 28756627.
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