Thromboelastometry in Patients Receiving Platelet Transfusion after Chemotherapy.

Abstract Prophylactic platelet transfusion is frequently administered to reduce the risk of hemorrhage in patients undergoing chemotherapy for leukemia or cancer. A platelet count of 10 or 20x109 L−1 is often used as an occasion for platelet transfusion. In clinical studies, the bleeding risk was similar using either threshold (Rebulla, NEJM1997; 337:1870, Wand, Blood1998; 91:3601). Moreover, serious bleeding events were not related to the patients’ platelet count. Thromboelastometry with ROTEM® Whole-Blood Coagulation Analyzer (Pentapharm, Munich, Germany) is a method that may provide a better estimate of the risk of hemorrhage because it also depends on platelet function and plasma coagulation. We therefore performed a pilot study in 13 adult patients receiving prophylactic platelet transfusion after chemotherapy for leukemia or lymphoma. ROTEM® was performed using an ellagic acid based activating reagent (in-TEM®, Pentapharm). Clotting profiles were evaluated using the following thromboelastometric measures: clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF). The median platelet count before transfusion was 9x109 L−1 (range 1 to 20). CT was within the normal range in all patients (median 168 s, range 125–212, reference range 100–240). In contrast, a prolonged CFT (median 139 s, range 51–4526, reference range 30–110) and reduced MCF (median 34 mm, range 19–54, reference range 50–72) was recorded. Correlation between platelet count and CFT (R=−0.41, Spearman) or MCF (R=+0.48) was weak and not statistically significant. 15 min after platelet transfusion, there was an increase in platelet count (median 39x109 L−1, range 23–48) and a substantial improvement of CFT (median 99 s, range 44–332) and MCF (median 49 mm, range 40–64). Changes in thromboelastometric measures were due to platelet transfusion as the addition of cytochalasin D (fib-TEM®, Pentapharm) resulted in identical profiles before and after transfusion. Changes in platelet count correlated with changes in MCF (R=+0.73, P<0.01), but not CFT (R=−0.40, P=0.17). Comparing patients who had a maximum of one mild bleeding symptom (n=9) with patients who experienced one severe or at least two mild bleeding symptoms (n=4), there was no difference in platelet counts (median 10 vs. 9x109 L−1, p=0.77). In contrast, there was a trend towards a shorter CFT (median 111 vs. 388 s, P=0.09) and higher MCF (median 39 vs. 29.5 mm, P=0.09) in the group of non-bleeding patients. In summary, ROTEM® seems to be a sensitive method to detect hemostatic changes in patients with severe thrombocytopenia receiving platelet transfusion and to identify thrombocytopenic patients with an increased bleeding risk. Therefore, further studies to evaluate ROTEM® as a means to estimate the bleeding risk in thrombocytopenic patients are warranted.

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Thromboelastographic Follow-Up Of Prophylactic Thrombocyte Transfusion

Blood ◽

10.1182/blood.v122.21.4826.4826 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4826-4826 ◽

Cited By ~ 1

Author(s):

Deniz Goren Sahin ◽

Olga M. Akay ◽

Mustafa Karagulle ◽

Eren Gunduz ◽

Zafer Gulbas

Keyword(s):

Platelet Count ◽

Economic Burden ◽

Platelet Transfusion ◽

Conflicts Of Interest ◽

Bleeding Risk ◽

Thrombocyte Count ◽

Platelet Counts ◽

Before And After ◽

Thrombocyte Transfusion

Introduction Prophylactic thrombocyte transfusion is being used to reduce increased bleeding risk after chemotherapy treatment for leukemia or malignancy. This transfusion is frequently applied when thrombocyte count is below <10.000/uL or between 10.000 and 20.000/uL. However, it was shown that thrombocyte count alone is not enough for determining bleeding risk. Moreover, given the fact that thrombocyte transfusions have inherent risks and economic burden, new laboratory approaches such as thromboelastography can be considered to determine bleeding risk in these patients. Thromboelastography is a new alternative method to conventional coagulation tests, which gives information about hemostatic system by evaluating clot’s visco-elastic and mechanical features. The aim of our study to establish a transfusion algorithm by thromboelastographic follow-up of prophylactic thrombocyte transfusion. Methods Eighty patients who have been diagnosed as acute leukemia were randomized into 4 groups. Six units random thrombocyte was given to the first group, three units random thrombocyte was given to the second group, one unit apheresis was given to the third group, and ½ unit apheresis was given to the fourth group. Before and 15 minutes after transfusion, peripheral blood was taken and CBC and rotation thromboelastograpy (ROTEM) was performed by standard device (Pentapharm GmbH, Munich, Germany). Clotting time (CT), clot formation time (CFT), and maximum clot firmness (MCF) were evaluated by 2 methods, in-TEM and ex-TEM. Patients were followed up during study by using clinical bleeding signs based on WHO bleeding grade. Patients who used medications that can affect thrombocyte functions within the last 14 days and patients who have systemic disorders (renal, hepatic, endocrinological) or hemostatic disorders were not included in this study. Variance analysis was used in order to find out statistical differences. P<0.05 was considered statistically significant. Results When platelet counts and ROTEM results were analyzed for each parameter before platelet transfusion, there were no statistically significant differences among groups. We analyzed the differences of platelet counts and thromboelastographic parameters before and after prophylactic platelet transfusion and we didn’t see any statistically significant differences between groups. Clinical bleeding signs were not correlated with platelet count in any groups. Conclusion Six units random, three units random, complete apheresis or half apheresis prophylactic platelet transfusion does not cause any significant changes in platelet count, ROTEM parameters and clinical bleeding signs. Therefore, low dose platelet transfusion can be considered because of its lower economic burden. Moreover, further studies are needed to evaluate the potential of ROTEM as an independent factor for transfusion indication. Disclosures: No relevant conflicts of interest to declare.

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Lusutrombopag is effective and safe in patients with chronic liver disease and severe thrombocytopenia: a multicenter retrospective study

BMC Gastroenterology ◽

10.1186/s12876-020-01573-9 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Hiroaki Nomoto ◽

Naoki Morimoto ◽

Kouichi Miura ◽

Shunji Watanabe ◽

Yoshinari Takaoka ◽

...

Keyword(s):

Platelet Count ◽

Liver Disease ◽

Chronic Liver Disease ◽

Platelet Transfusion ◽

Chronic Liver ◽

Severe Thrombocytopenia ◽

Invasive Procedures ◽

Significance Level ◽

Group A ◽

Group B

Abstract Background Chronic liver disease (CLD) is often complicated by severe thrombocytopenia (platelet count < 50,000/µL). Platelet transfusion has been a gold standard for increasing the platelet count to prevent hemorrhagic events in such patients. Lusutrombopag, a thrombopoietin receptor agonist, can increase the platelet count in such patients when invasive procedures are scheduled. Former studies on lusutrombopag included patients with a platelet count of > 50,000/µL at baseline: the proportions of patients who did not require platelet transfusion were 84–96%, which might be overestimated. Methods The efficacy and safety of lusutrombopag were retrospectively investigated in CLD patients with platelet count of < 50,000/µL, a criterion for platelet transfusion, in real-world settings. We examined the proportion of patients who did not require platelet transfusion in 31 CLD patients, which exceeded a minimum required sample size (21 patients) calculated by 80% power at a significance level of 5%. Lusutrombopag, 3 mg once daily, was administered 8–18 days before scheduled invasive procedures. Results Among 31 patients who received lusutrombopag, 23 patients (74.2%) patients showed a platelet count of ≥ 50,000/µL (Group A) and did not require platelet transfusion. The remaining 8 patients (25.8%) did not reached platelet ≥ 50,000/µL (Group B). The means of platelet increase were 38,000/µL and 12,000/µL in groups A and B, respectively. A low platelet count at baseline was a characteristic of patients in group B. Among 13 patients who repeatedly used lusutrombopag, lusutrombopag significantly increased the platelet count as the initial treatment. When all repeated uses of lusutrombopag were counted among these 13 patients, platelet transfusion was not required in 82.1% (23/28) of treatments. Although one patient showed portal thrombosis after lusutrombopag treatment, the thrombosis was disappeared by anticoagulant treatment for 35 days. The degree of platelet increase with lusutrombopag was larger than that in their previous platelet transfusion. Conclusions The proportion of patients who did not require platelet transfusion was 74.2%, which is smaller than that in former studies which included CLD patients with a platelet count of > 50,000/µL. However, lusutrombopag is effective and safe for CLD patients with a platelet count of < 50,000/µL.

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Assessing Bleeding Risk in Pediatric Patients Undergoing Major Spinal Surgery

Blood ◽

10.1182/blood.v126.23.3518.3518 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3518-3518

Author(s):

Jennifer Anadio ◽

Adam Lane ◽

Cristina Tarango ◽

Peter Sturm ◽

Joseph S. Palumbo

Keyword(s):

Platelet Count ◽

Platelet Transfusion ◽

Pediatric Patients ◽

Bleeding Risk ◽

Bleeding Disorder ◽

Bleeding Complications ◽

Type I ◽

Preoperative Screening ◽

History Of ◽

Clinically Significant

Abstract Preoperative screening for bleeding disorders in pediatric patients is problematic due to children's limited exposures to significant hemostatic challenges and the inherent difficulty in obtaining blood samples from young patients. Overcoming these challenges is of particular importance for surgical procedures that carry a significant bleeding risk, such as spinal surgeries. Many pediatric surgeons, including the Pediatric Orthopedic team at our Institution, rely on an unfocused history and measurement of general markers of hemostasis for preoperative screening. In order to improve preoperative screening of pediatric patients undergoing spinal procedures, we instituted the use of a detailed semi-quantitative questionnaire based on the ISTH Bleeding Assessment Tool (BAT), in combination with evaluation of PT, aPTT, platelet count, and PFA. The BAT gives positive points for a personal or family history of bleeding, and negative points for significant hemostatic challenges that did not result in bleeding complications. It was decided a priori that a BAT score of ≥3 would result in referral to Pediatric Hematology. A total of 212 patients presenting for major spinal surgeries (e.g., spinal fusion, growth rod placement) ranging in age from 3 to 25 years were prospectively evaluated in this fashion. A total of 41 patients (19.3%) had a prolongation of the PT and/or aPTT, none of which had a high BAT score. The majority of the abnormal PT/aPTT values were minimal prolongations that were not reproducible on repeat testing. Prolongation of the PT and/or aPTT revealed 3 patients with mild deficiencies of either factors VII, X, or XI, none of which were felt to be clinically significant. Prolonged PFAs were observed in 32 patients (16%), 1 of which was diagnosed with type I VWD (BAT score = 1), and the other with "possible VWD" based on a borderline VWF antigen level (BAT score = 0). Both were treated with Humate P. The remainder of the patients with a prolonged PFA were determined not to have a significant bleeding disorder after further testing. A total of 15 patients were referred to Hematology based on a high BAT score. Of these, 2 had a history of thrombocytopenia (1 with known DiGeorge syndrome and 1 with Depakote-related thrombocytopenia). Neither required platelet transfusion. One patient with a high BAT score was known to have type I VWD and was treated with Humate P, another was diagnosed with low expression of glycoprotein GP1b and was treated with Humate P and platelet transfusion. The remainder of the patients with high BAT scores were not felt to have a clinically significant bleeding disorder based on a Hematologist's assessment. None of the 212 patients evaluated were felt to have excessive intraoperative bleeding by the surgical team, suggesting that none of the patients had a significant undiagnosed hemostatic defect. Together, these results suggest that reliance on history or screening labs alone may not be sufficient for many pediatric surgery patients. While the PFA identified 2 patients with mild/possible VWD that would have been missed by the BAT, the PFA also had a significant number of apparent false positives. The combination of a BAT and a platelet count, as well as assessment of VWF activity for patients without previous hemostatic system challenges, may provide a more effective screening methodology for institutions with ready access to VWF activity measurement. Disclosures No relevant conflicts of interest to declare.

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The Burden of Clinically Significant Bleeding, Thrombocytopenia and Platelet Transfusions in Myelodysplastic Syndromes

Blood ◽

10.1182/blood-2019-125273 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 719-719

Author(s):

Kathleen Pao Lynn Cheok ◽

Rakchha Chhetri ◽

Li Yan A Wee ◽

Arabelle Salvi ◽

Simon McRae ◽

...

Keyword(s):

Risk Factors ◽

Antiplatelet Therapy ◽

Myelodysplastic Syndromes ◽

Cumulative Incidence ◽

Platelet Transfusion ◽

Severe Thrombocytopenia ◽

Bleeding Events ◽

Platelet Counts ◽

Immune Mediated ◽

Platelet Transfusions

Aim: Although 40-65% of myelodysplastic syndromes (MDS) patients are thrombocytopenic and require platelet transfusions, there is limited literature on the risk factors predictive of bleeding and the burden of immune mediated platelet refractoriness (PLT-R). Objectives: To evaluate the prevalence of thrombocytopenia, incidence of bleeding events, platelet transfusion dependency (PLT-TD) and immune-mediated platelet refractoriness (PLT-R) in MDS patients. Methods: A retrospective analysis of 754 MDS patients enrolled in the South Australian MDS (SA-MDS) registry was performed. Platelet counts <100, <50 and <20 (x109/L) were used to define mild, moderate and severe thrombocytopenia respectively. The severity of bleeding events was classified according to the International Society of Thrombosis and Haemostasis (ISTH) classification. PLT-TD was defined as transfusion of at least one unit of platelets each month for four consecutive months. All other patients were classified as transfusion independent (PLT-TI). Immune mediated PLT-R was defined if a patient had HLA-class I or HPA antibodies, poor platelet increments and required HLA-matched platelets. Medication history with regards to anticoagulation and/or antiplatelet therapy was also collected. Results: At diagnosis, 332 (45%) patients had thrombocytopenia and 106 (14%) patients had moderate to severe thrombocytopenia. During the study period, 249 bleeding events were recorded in 162 (21%) patients with a cumulative incidence of 33% (Fig 1A). Of the 249 bleeding events, 85 (34%) were major and 164 (66%) were clinically relevant minor bleeding. Notably, 16, 90 and 5 bleeding events were intracranial, gastrointestinal, intraocular respectively. While 41% (96/235) bleeding events occurred in the setting of moderate to severe thrombocytopenia, 21% and 38% (Fig 1B) of bleeding events occurred at platelet counts of >50-100 and >100x109/L respectively. Twenty-eight percent (69/249) bleeding events were associated with concomitant anticoagulation and/or antiplatelet therapy and importantly, platelets counts were >50x109/L and >100 x109/L in 57 (83%) and 46 (67%) at the time of bleeding events, respectively. During the disease course, 393 (52%) patients required at least one unit of platelet transfusion. 106 (14%) patients were PLT-TD and had significantly poor overall survival (OS) compared to PLT-TI (26 vs 42 months, p<0.0001). In total, 30/393 (7%) required HLA-matched platelet transfusions. 20/30 (66%) of PLT-R patients were female receiving disease modifying therapy (DMT). This was substantiated by cox regression analysis, demonstrating that females (HR=5.32, p=0.0006), older age (HR=0.97, p=0.028) and haemoglobin (Hb) at diagnosis (HR=1.03, p=0.009) were independent risk factors for PLT-R. Importantly, 20/76 (25%) female patients receiving platelets and DMT developed immune mediated PLT-R requiring HLA matched platelets. Conclusions: In our cohort of MDS patients, cumulative incidence of bleeding is 33% and 59% of the bleeding events occurred at platelet counts >50X109/L. For all bleeding events that occurred while on anticoagulation and/or antiplatelet therapy, 83% events occurred with platelet counts >50 x 109/L. Therefore, guidelines for anticoagulation and/or antiplatelet therapy are required for MDS patients. We also showed that development of PLT-TD is associated with poor OS. Importantly, 1 in 4 female MDS patients receiving platelets and DMT required HLA-matched platelets. Platelet transfusions practices should be optimised for these high-risk groups. Disclosures No relevant conflicts of interest to declare.

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Safety of Lumbar Punctures in Adult Oncology Patients with Thrombocytopenia

Blood ◽

10.1182/blood.v126.23.1141.1141 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1141-1141 ◽

Cited By ~ 1

Author(s):

Shuoyan Ning ◽

Brent Kerbel ◽

Jeannie Callum ◽

Yulia Lin

Keyword(s):

Risk Factors ◽

Platelet Count ◽

Platelet Transfusion ◽

Conflicts Of Interest ◽

Tertiary Care ◽

Bleeding Risk ◽

Von Willebrand Disease ◽

Oncology Patients ◽

Platelet Counts ◽

Hemorrhagic Complications

Abstract Introduction: Lumbar puncture (LP) is a frequently performed diagnostic and therapeutic intervention in adult oncology patients. While thrombocytopenia is common in this patient population, the minimum "safe" platelet count required for LPs is unknown. Recent guidelines from the AABB (American Association of Blood Banks) recommend a pre-procedure platelet count of 50 x 109/L. However this recommendation is largely based on expert opinion, and there remains a paucity of studies in the adult oncology literature to address this important question. Methods: We retrospectively reviewed all oncology patients ≥18 years who underwent 1 or more LPs over a 2 year period at a single tertiary care institution to determine 1) the range of platelet counts at which LPs are performed; 2) the rate of traumatic taps; and 3) the rate of hemorrhagic complications. Laboratory, clinical, and transfusion information were extracted through the Laboratory Information System, chart review, and blood bank database, respectively. Thrombocytopenia was defined as a platelet count of < 150 x 109/L. Pre-LP platelet counts were those collected ≤24 hours from, and closest to the time of the LP. The following bleeding risk factors were documented: end stage renal disease; platelet dysfunction; von Willebrand disease; hemophilia. Anticoagulation, anti-platelet, and non-steroidal inflammatory use was also recorded, with accuracy limited by the study's retrospective nature. All patients with coagulopathy were excluded (INR ≥ 1.5, aPTT ≥ 40, fibrinogen ≤ 1.0). Traumatic tap was defined as 500 or more red blood cells per high-power field in the cerebrospinal fluid. A follow up of 1 week after LP was used to capture any hemorrhagic complications. Results: From January 2013 to December 2014, 135 oncology patients underwent 369 LPs; 64 (47.4%) patients were female, and the mean age was 59 years (range 20-87). 119 (88.1%) patients had a primary hematological diagnosis. 113 (30.6%) LPs were performed in thrombocytopenic patients. 28 (7.6%) procedures had a pre-procedure platelet count of ≤ 50 x 109/L, with 18 receiving a single platelet transfusion on the day of the LP. Of these 18 transfusions, only 1 had a post-transfusion platelet count available prior to LP with no improvement in platelet count (33 x 109/L). 15 transfusions had post-LP platelet counts within 24 hours of the transfusion (8 below 50 x 109/L with lowest 14 x 109/L), 1 had post-LP platelet count within 24-48 hours (54 x 109/L) and 1 did not have a post-transfusion platelet count. Traumatic taps occurred in 17 (15.0%) LPs in patient with thrombocytopenia, compared to 26 (11.0%) LPs in patients with a normal platelet count (fisher's exact test P=0.39). There was 1 traumatic tap in a patient with a pre-LP platelet count of ≤ 50 x 109/L; however, this patient received a pre-LP platelet transfusion for a platelet count of 42 x 109/L and had a post-LP platelet count of 66 x 109/L. Presence of bleeding risk factors did not increase the risk of a traumatic tap (present in 48.8% of traumatic taps vs. 88.3% of non-traumatic taps). There were no hemorrhagic complications. Conclusion: Among this cohort of adult oncology patients undergoing diagnostic and therapeutic LPs, there were no hemorrhagic complications. There was no significant increase in traumatic taps in patients with thrombocytopenia or bleeding risk factors. While platelet transfusions were frequently administered for patients with a platelet count of ≤ 50 x 109/L, post-transfusion platelet counts were infrequently assessed prior to the procedure. Our findings question whether a platelet transfusion threshold of 50 x 109/L is necessary for lumbar puncture.Table 1.Platelet Count Pre-LP(x109/L)Number of LPsNumber of Traumatic TapsNumber of Hemorrhagic Complications0-90N/AN/A10-2030021-5070051-1003380101-1495270> 150242270Unknown1400< 50 x 109/L and received platelet transfusion on day of LP181*0Total369430*There was one traumatic tap in a patient with a platelet count of 42 x 109/L who received a platelet transfusion pre-LP. The post transfusion platelet count was 66 x 109/L. Disclosures No relevant conflicts of interest to declare.

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Severe Thrombocytopenia Does Not Increase Bleeding Complications in Patients Undergoing Bronchoscopy

Blood ◽

10.1182/blood.v124.21.4293.4293 ◽

2014 ◽

Vol 124 (21) ◽

pp. 4293-4293

Author(s):

Lakshminarayanan Nandagopal ◽

Muthu Veeraputhiran ◽

Tania Jain ◽

Ayman Soubani ◽

Charles A. Schiffer

Keyword(s):

Platelet Count ◽

Renal Dysfunction ◽

Platelet Transfusion ◽

Conflicts Of Interest ◽

Bleeding Complications ◽

British Thoracic Society ◽

Severe Thrombocytopenia ◽

Platelet Counts ◽

Number Of Patients ◽

Platelet Transfusions

Abstract Introduction Prophylactic platelet transfusions are often performed prior to bronchoscopy or broncho-alveolar lavage (BAL) to prevent bleeding in thrombocytopenic patients. There is a paucity of data to validate this approach, with a platelet transfusion threshold of <50,000/mm3 largely based on expert opinion. We conducted a retrospective study on the incidence of bleeding complications in thrombocytopenic patients undergoing bronchoscopy. Methods We identified 150 consecutive patients with platelet counts <100,000/mm3 who underwent bronchoscopy and/or BAL from January 2009 to May 2014 at our institution. Bronchoscopies performed in patients with frank hemoptysis and trans-bronchial lung biopsy procedures were excluded. Patient characteristics, underlying diagnosis, platelet count prior to bronchoscopy, administration of platelet transfusions and bronchoscopy details were recorded. Factors affecting bleeding risk including presence of renal dysfunction (defined as BUN >30 and/or Cr>2.0) and coagulation studies (PT, PTT, INR) were identified. The British Thoracic Society guidelines1 were used to categorize bleeding as a result of bronchoscopy. Data were analyzed using descriptive statistics. Results The median age was 59 years (range 27-90), with two-thirds of patients (63%) being male. One hundred and seventeen (78%) patients had underlying malignancy and 55 (37%) had thrombocytopenia related to malignancy. Fellows and residents under the supervision of a bronchoscopy certified attending performed all but 4 of the bronchoscopies. Infection (40%) was the primary indication for bronchoscopy with BAL performed in 127 (85%) patients. Fifty-eight of 89 (65%) patients with baseline platelet counts <50,000/mm3 received prophylactic transfusions compared to 8% of those with platelet counts >50,000/mm3. The platelet count did not rise to >50,000//mm3 in many transfused patients. Seventy patients (47%) had counts <50,000/mm3 and eighty patients (53%) had counts >50,000/mm3 at the time of bronchoscopy. 49% were receiving immunosuppressive medications, 45% had renal dysfunction and 8% had INR >1.5. Bloody lavage that resolved spontaneously without continuous suctioning (Grade 0) was observed in 9 (6%) patients. Bleeding that required continuous suctioning but then resolved spontaneously (Grade 1) was noted in 1 patient with a platelet count of 61,000/mm3. Of 10 total bleeding events, 7 occurred in patients who were intubated. Two additional patients with platelet counts of 30,000/mm3 and 53,000/mm3 had diffuse alveolar hemorrhage, which was present before bronchoscopy. “Old” blood and blood clots were observed in 6 patients. Discussion The low incidence of bleeding complications from bronchoscopy +/- BAL even in patients with platelet counts <30,000/mm3 (3 episodes in 31 patients, all grade 0) demonstrates that bronchoscopy can be safely done in severely thrombocytopenic patients. Adopting a lower threshold for prophylactic transfusions could save a considerable number of platelet units and translate into significant cost savings and decreased risk of transfusion-related complications. Table 1 Platelet count, transfusion history and bleeding complications during bronchoscopy Platelet count at the time of bronchoscopy Number (n) and percentage (%) of patients who underwent bronchoscopy Number of patients who received prior platelet transfusion Bleeding during bronchoscopy n % 0-15,000/mm3 9 6% (9/150) 5 Grade 0=1 pt 16-29 22 15% 16 Grade 0=2 pts 30-39 17 11% 9 Grade 0=1 pt 40-49 22 15% 9 Grade 0=3 pts 50-75 44 29% 14 Grade 1=1 pt 76-100 36 24% 10 Grade 0=2 pts Total 150 63 Grade 0=9 pts, Grade 1=1 pt. 1.Du Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax. 2013:68 Suppl 1:i1-i44 Disclosures No relevant conflicts of interest to declare.

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Bleeding Complications in Ultrasound-Guided Central Venous Access in Patients with Severe Thrombocytopenia: A Propensity Score-Based Analysis

10.21203/rs.3.rs-809745/v1 ◽

2021 ◽

Author(s):

Virginia Zarama ◽

Jorge A. Revelo-Noguera ◽

Jaime A. Quintero ◽

Ramiro Manzano ◽

Francisco L. Uribe-Buriticá ◽

...

Keyword(s):

Logistic Regression ◽

Platelet Count ◽

Platelet Transfusion ◽

Central Venous Access ◽

Venous Access ◽

Catheter Placement ◽

Bleeding Complications ◽

Severe Thrombocytopenia ◽

Ultrasound Guided ◽

Central Venous

Abstract Purpose: To study the occurrence of bleeding complications in patients with severe thrombocytopenia (platelet count <20x103/µL) subjected to ultrasound-guided central venous access (UG-CVA) while receiving or not routine prophylactic platelet transfusion (PPLT).Research Question: What is the frequency of bleeding complications related to the placement of ultrasound-guided central venous access in patients with severe thrombocytopenia between 2011 and 2019 at high complexity hospital?Methods: A total of 221 patients with severe thrombocytopenia subjected to UG-CVA from January 2.011 to November 2.019 were selected. They were classified as positive (P-PPLT) or negative (N-PPLT) recipients of PPLT. Then, P-PPLT (n=72) were 1:1 propensity matched to N-PPLT based on catheter diameter, anatomical insertion site, presence of hematologic malignancy, absolute platelet count and whether the health care provider performing the procedure was an attending or a trainee. Bleeding complications were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) score and adapted to central venous catheter placement. A logistic regression analysis was then performed using “bleeding complications” as a binary compound outcome of major (Grades 3-4) and minor bleeding (Grades 1-2) vs. no bleeding.Results: Seventy-two patients were classified as P-PPLT, while 149 as N-PPLT. No grades 3-4 of bleeding events were identified in the entire population. No significant differences were observed between N-PPLT and P-PPLT for bleeding Grades 1-2 in both pre-matched (53[35.5%] vs. 26[36.1%], p=0.90) and propensity-matched populations (27[37.5%] vs. 26[36.1%], p=0.80). Logistic regression demonstrated that PPLT did not influence any bleeding complication (OR 0.9, 95%CI 0.42-1.92, p=0.791)Conclusions: Bleeding complications related to central venous catheterization in acutely ill patients with severe thrombocytopenia are not influenced by routine prophylactic platelet transfusion when catheter placement is performed under ultrasound guidance.

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“MATERNAL OUTCOME IN PREGNANCY WITH THROMBOCYTOPENIA”

10.36106/ijsr/9409085 ◽

2021 ◽

pp. 12-15

Author(s):

Uma Jain ◽

Preeti Gupta ◽

Deepali Jain

Keyword(s):

Platelet Count ◽

Platelet Transfusion ◽

Normal Pregnancy ◽

Maternity Hospital ◽

Severe Thrombocytopenia ◽

Fetal Outcomes ◽

Puerperal Sepsis ◽

Frequent Monitoring ◽

Gestational Thrombocytopenia ◽

In Pregnancy

INTRODUCTIONThrombocytopenia is diagnosed when the platelet count is less than 1,50,000 per microliter of blood It is a common hematological disorder Thrombocytopenia is divided into 3 types according to severity: mild (100,000 to 150,000), moderate (50,000to100,000) and severe (less than 50,000) thrombocytopenia. MATERIALAND METHODObjective- To study the incidence of thrombocytopenia in normal pregnancy. to study the maternal and fetal outcomes in pregnant patients with thrombocytopenia This is a retrospective study in which a total of 1202 patients delivered in a maternity hospital of Gwalior from 1 January 2018 to 30 June 2019 were studied. 72 patients with a platelet count below 1.5 lakhs were included in the study. RESULTSA total of 1202 patients were delivered during the study period out of the 72 patient had thrombocytopenia thus the prevalence was found to be 5.99%. rd In our study majority of the patients were multigravida 63.88% in the 3 trimester 54.16% majority by between age of 25-30 years 58.33%. In our study 61.11% of women had mild, 27.77 had moderate and 11.11% had severe thrombocytopenia. In this study, gestational thrombocytopenia was the most common etiological factor with 29.16% of cases. In our study, 70.83% of patients were delivered vaginally and 29.16% of patients were delivered by LSCS. No complication was reported in 48.61% of patients. The bleeding during CS was found in 4.16% cases, maternal hemorrhage was found in 5.55%, pulmonary edema in 5.55%, ARF in 5.55%, DIC 4.16%, and Puerperal sepsis in 2.77%. Blood transfusion was needed in 15.27% of patients, platelet transfusion in 4.16% of patients. Obstetric hysterectomy was done in 1 patient. During the study, 2 maternal death were reported due to the HELLPsyndrome and associated complications. CONCLUSIONGestational thrombocytopenia is the most common cause of thrombocytopenia during pregnancy. We conclude that early diagnosis of thrombocytopenia in pregnancy is essential for better maternal and fetal outcomes. It is important to determine the exact etiological cause of thrombocytopenia so that timely management can be provided to the pregnant patients to decrease the complication rate thus, timely diagnosis, frequent monitoring, and treatment is must achieve a better outcome.

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A Therapeutic Platelet Transfusion Strategy without Routine Prophylactic Transfusion Is Feasible and Safe and Reduces Platelet Transfusion Numbers Significantly: Preliminary Analysis of a Randomized Study in Patients after High Dose Chemotherapy and Autologous Peripheral Blood Stem Cell Transplantation

Blood ◽

10.1182/blood.v112.11.286.286 ◽

2008 ◽

Vol 112 (11) ◽

pp. 286-286 ◽

Cited By ~ 5

Author(s):

Hannes Wandt ◽

Knut Wendelin ◽

Kerstin Schaefer-Eckart ◽

Markus Thalheimer ◽

Mario Stephan Schubert ◽

...

Keyword(s):

Multiple Myeloma ◽

Risk Factor ◽

Platelet Count ◽

Platelet Transfusion ◽

Additional Risk Factor ◽

Transfusion Strategy ◽

Bleeding Events ◽

Additional Risk ◽

Mucosal Bleeding ◽

Platelet Transfusions

Abstract We performed a multicenter randomized trial comparing the traditional prophylactic platelet transfusion strategy -arm P- (trigger: morning platelet count ≤ 10/nL) with an experimental therapeutic transfusion strategy -arm T- where patients (pts) received platelet transfusions only if they experienced clinically relevant bleeding (more than petechias or minimal mucosal bleeding). The morning platelet count was no trigger in arm T for transfusion as well as fever per se. Fever was no additional risk factor for bleeding in thrombocytopenic pts treated with our therapeutic transfusion strategy as published recently. (Wandt, H et al. Bone Marrow Transplant2006; 37:387–392) For safety reasons prophylactic transfusion was recommended in arm T, however, for pts with invasive aspergillosis, sepsis syndrome and unexpected headache. Randomisation was stratified according to age (<50 years), sex and center. Different diagnoses (multiple myeloma, non Hodgkin’s lymphoma, Hodgkin’s disease, acute leukemia) were well balanced between both arms. One hundred seventy one consecutive pts with a median of 56 years (19–68) who signed informed consent were included in the study. Primary objective was a reduction of platelet transfusions of 15–25%; secondary objectives were safety, duration of leuko- and thrombocytopenia, hospitalisation, and numbers of red blood cell transfusion. Red blood cells should be transfused when hemoglobin level dropped below 8 g/dL or as clinically indicated. Results: Platelet transfusions could be reduced significantly by 27% in arm T compared with arm P (p0.004). In arm T 46% of pts did not need any platelet transfusion and this was more than the double compared to arm P (0.001). Between younger and older pts there was no difference in numbers of platelet transfusions needed. Overall, adherence to the protocol was good. Since clinically relevant bleeding (more than petechias and minimal mucosal bleeding) was the trigger for platelet transfusion in arm T consequently more such hemorrhages occured in arm T (28.7% vs 9.5%). No life threatening or fatal bleeding was registered. Hemorrhages were mainly (21.8%) epistaxis or mucosal, 6.9% were minor bleedings (e.g. vaginal, hematochezia, hemoptysis, hematuria). One pt with sudden headache had a minor cerebral hemorrhage (subarachnoid) documented by ct-scan without any clinical sequelae. Days with hemorrhage overall were rare but significantly increased in arm T (0.69 vs 0.17 days per pt). Age was no risk factor for bleeding. As already expected by our former experience we could show that fever and infection were no additional risk factor for bleeding in arm T compared with arm P despite the very stringent platelet transfusion strategy in the experimental transfusion arm. In pts with multiple myeloma bleeding events were very rare compared to other diagnoses (p <0.0001). Numbers of red blood cell units were not significantly different between the two arms, as well as the duration of leukocytopenia and hospitalisation. In contrast duration of thrombocytopenia <20/nL was significantly longer in arm T (median 5 vs 3 days; p 0.004) as expected. We conclude that our therapeutic platelet transfusion strategy is cost effective and safe in pts after autologous stem cell transplantation. Despite more minor hemorrhages in the experimental arm compared with the traditional prophylactic strategy all bleeding events could be safely controlled by consecutive platelet transfusion. Development of major bleeding could be prevented by the therapeutic transfusion strategy according to our protocol.

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Retrospective Analysis of Thrombocytopenia in Relapsed Multiple Myeloma Patients

Blood ◽

10.1182/blood.v118.21.5073.5073 ◽

2011 ◽

Vol 118 (21) ◽

pp. 5073-5073 ◽

Cited By ~ 1

Author(s):

Angela M Sousa ◽

Federico Campigotto ◽

Donna Neuberg ◽

Diane Warren ◽

Paul G. Richardson ◽

...

Keyword(s):

Clinical Trial ◽

Multiple Myeloma ◽

Platelet Count ◽

Platelet Transfusion ◽

Treatment Initiation ◽

Transfusion Requirement ◽

Bleeding Events ◽

Treatment Regimens ◽

The Impact ◽

Platelet Transfusions

Abstract Abstract 5073 Introduction Despite improvement in patient (pt) outcomes in recent years, multiple myeloma (MM) remains incurable and nearly all pts relapse after initial response to therapy. With disease progression and cumulative exposure to chemotherapeutic agents, pts with relapsed MM frequently develop cytopenias that represent a significant clinical challenge. At present, management of high-grade thrombocytopenia at our institution consists of supportive platelet transfusions. We hypothesize that thrombocytopenia is a highly relevant variable in the overall management of relapsed MM. As there are currently no studies in the myeloma literature that assess the impact of thrombocytopenia, we conducted a retrospective, chart-review study to evaluate the impact of thrombocytopenia in relapsed MM. Methods Participants included all pts with relapsed and/or relapsed-refractory MM who participated in clinical trials at Dana Farber Cancer Institute from January 1, 2007 – December 31, 2009. Many pts participated in more than one clinical trial during this time period. In this analysis, therapy administered to a particular patient in the context of one clinical trial is referred to as a “treatment regimen.” The overall incidence of thrombocytopenia (platelet count < 150,000/mcl) at initiation of a treatment regimen was recorded. The incidence of severe thrombocytopenia (platelet count < 100,000/mcl and < 75,000/mcl) was also determined. Medical record data collected to assess the clinical impact of thrombocytopenia included the following variables: episodes of ≥ grade 3 thrombocytopenia, number of platelet transfusions per pt per month on clinical trial, treatment delays and treatment discontinuations due to thrombocytopenia, the occurrence of bleeding events, and overall survival on clinical trial therapy. Point estimates with exact binomial confidence intervals and median and range are used to describe the data. The differences in platelet transfusion requirements were assessed by the two-sided Wilcoxon rank sum test. Results To date, data has been abstracted on 43 treatment regimens in 23 pts. Fifteen pts had previously undergone autologous stem cell transplantation (ASCT), including two who had undergone tandem auto-transplant. The overall incidence of thrombocytopenia (platelet count < 150,000/mcl) was 40% at time of treatment initiation. In 13 of the 43 (30%, 90% Confidence Interval (CI)) treatment regimens, the platelet count at time of treatment initiation was less than 100,000/mcl. The platelet count at time of treatment initiation was less than 75,000/mcl in 11 of 43 (25%, 90%CI) treatment regimens reviewed. Cases where the platelet count was ≤ 100,000/mcl at time of study entry, mean platelet transfusion requirement per 4-week time interval was 2.35 units, while in cases where the platelet count was ≥ 100,000/mcl, the mean platelet transfusion requirement was 0.20 units transfusions per 4 week period was needed (p <.0001). In 20 (47%, 90% CI) of the treatment regimens reviewed, bortezomib was part of the therapeutic regimen. Data revealed no significant difference in requirement for platelet transfusion between regimens that included bortezomib versus those that did not. Two pts experienced a bleeding event during their treatment regimens. The platelet count at the time of the bleeding events was 57,000/mcl and 154,000/mcl. Treatment was delayed for one pt due to thrombocytopenia, and two pts were removed from study due to thrombocytopenia. Overall rate of survival at 1-year among 23 pts assessed to date was 91%. Conclusion Thrombocytopenia is a common problem in this pt population, particularly in pts that begin treatment with a platelet count < 100,000/mcl. This results in increased platelet transfusions, which are associated with heightened cost of health care and risk of transfusion related toxicities (ex. platelet alloimmunization). Complications related to thrombocytopenia such as bleeding events and treatment discontinuation are relatively rare; this is likely due to routine use of platelet transfusion. Of note, the incidence of transfusion is likely underrepresented by this retrospective study because intact bone marrow function is an eligibility criterion for most clinical trials involving pts with relapsed MM. This data supports the need for improved therapies that minimize transfusion support in this population. Disclosures: Richardson: Millennium:; Celgene:; Johnson & Johnson:; Novartis:; Bristol Myers Squibb:. Anderson:Celgene: Consultancy, Honoraria; Millennium Pharmaceuticals, Inc.: Consultancy, Honoraria; Novartis: Consultancy, Honoraria.

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