Platelet transfusions for critically ill patients with thrombocytopenia

Abstract Background: Thrombocytopenia is a common complication of critical illness and an independent risk factor for death in the intensive care unit (ICU). Whether platelet transfusions modify the risk of death in critically ill patients is unknown. Methods: Adult patients admitted to ICU who received one or more platelet transfusion over a 10-year period (2006 - 2015) from 3 academic hospitals in Canada were analyzed from a blood transfusion registry. Oncology patients were excluded. Contemporaneous non-transfused ICU patients were used as controls. Data from the registry were validated by integrity checks with medical records and laboratory information systems. We estimated the effect of platelet transfusion on mortality in ICU adjusted for baseline and time-varying covariates including multi-organ dysfunction score (MODS) and severity of thrombocytopenia using a stratified cox proportional hazards model. Significance was set at p<0.05 for all analyses. Results: Of 43,234 non-oncology patients admitted to ICU, 5,621 (13.0%) received one or more platelet transfusion. Compared with non-transfused controls, transfused patients had lower platelet counts (median, 82 x109/L vs. 163 x109/L); were more often admitted after surgery (90.7% vs. 46.9%) especially cardiac surgery (86.8% of surgeries vs. 60.6%); and had higher unadjusted mortality (10.7% vs. 6.5%). Using regression analysis adjusted for covariates (nadir platelet count, red blood cell transfusion, need for hemodialysis) and stratified by age, baseline MODS score (available for 66.2% of patients) and need for invasive mechanical ventilation, platelet transfusions were associated with a lower risk of death in ICU [hazard ratio (HR)= 0.66; 95% confidence interval (CI), 0.46 - 0.96; p= 0.028; n= 26,404 with all available data]. A similar effect was observed in the subgroup of cardiac surgery patients (HR= 0.50; 95% CI, 0.26 - 0.98; p=0.044; n= 10,676) but not all surgical patients (HR = 0.73; 95% CI, 0.46 - 1.17; p= 0.188; n= 14,461). Conclusion:After adjusting for illness severity, thrombocytopenia and other confounders common among critically ill patients, platelet transfusions were associated with improved survival in the population of mostly cardiac surgery patients. This potential protective effect of platelet transfusions requires further evaluation in prospective studies. Disclosures Arnold: Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

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A UK national survey of prophylactic platelet transfusion thresholds in non-bleeding, critically ill adults

10.1101/2020.09.02.20186700 ◽

2020 ◽

Author(s):

Akshay Shah ◽

Doug W Gould ◽

James C Doidge ◽

Paul Mouncey ◽

David A Harrison ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Platelet Transfusion ◽

Online Survey ◽

Percutaneous Tracheostomy ◽

Transfusion Practice ◽

Research Centre ◽

Current Guideline ◽

Transfusion Threshold ◽

Platelet Transfusions

Thrombocytopaenia is common in critically ill patients and associated with poor clinical outcomes. Current guideline recommendations for prophylactic platelet transfusions, to prevent bleeding in critically ill patients with thrombocytopaenia, are based on observational data. Recent studies conducted in non-critically ill patients have demonstrated harm associated with platelet transfusions and have also called into question the efficacy of platelet transfusion. To date, there are no well-conducted randomised controlled trials (RCTs) evaluating platelet transfusion in critically ill patients. To inform the design of such an RCT, we sought to characterise current clinical practice across four commonly encountered scenarios in non-bleeding critically ill adult patients with thrombocytopaenia. An online survey link was sent to Clinical Directors and contacts of all adult general ICUs participating in the Intensive Care National Audit and Research Centre Case Mix Programme national clinical audit (n=200). The survey collected data regarding the respondents place of work, training grade and their current individual practice and possible limits of equipoise for prescribing prophylactic platelet transfusions across four scenarios: prophylaxis but with no procedure planned (NPP); ultrasound guided insertion of a right internal jugular central venous catheter (JVI); percutaneous tracheostomy (PT); and surgery with a low bleeding risk (SLBR). After excluding nine responses with missing data on all four of the main questions, responses were received from 99 staff, covering 78 ICUs (39.0% of 200 ICUs invited to participate). While nearly all respondents (98.0%) indicated a platelet transfusion threshold of 30 x 10^9/L or less for patients with no planned procedure, thresholds for planned procedures varied widely and centred at medians of 40 x 10^9/L for JVI (range: 10 to 70), 50 x 10^9/L for SLBR (range: 10 to 100) and 70 x 10^9/L for PT (range: 20 to greater than 100). Current platelet transfusion practice in UK ICUs prior to invasive procedures with relatively low bleeding risks is highly variable. Well-designed studies are needed to determine the optimal platelet transfusion thresholds in critical care.

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