Laparotomy Exploration In Pediatric With Severe Thrombocytopenia: A Report

Introduction: Perioperative bleeding in patients was a serious problem in the exploration of laparotomy, especially in severe thrombocytopenia patients. In addition, spontaneous bleeding often occurs in patients who have a platelet count of less than 10 to 20.109 cells. L-1 blood. When surgery must be performed on a patient with platelet counts < 50.109 cells L-1, platelet concentrate was urgently needed to be transfused during induction of anesthesia. Benefits and risks of transfusion before surgery had to be done on a per-patient basis. The available data was very limited in informing perioperative management of patients with thrombocytopenia. However, there have been previous reports of surgery cases in 66-year-old patients with a history of immune thrombocytopenia (ITP) and diagnosed with acute appendicitis related to disseminated intravascular coagulation (DIC), showing excellent postoperative hemostasis. Another one, a seven-year-old boy who has a severe refractory case of ITP with very low platelet counts was referred to urgent splenectomy performed without increase platelet counts before, and then the patient underwent plasma exchange (PE) after surgery. Those reports aimed to present 2 cases of laparotomy exploration in pediatric patients with severe thrombocytopenia. Case Report: The first laparotomy exploration was conducted on an 11-year-old boy who suffered acute perforated appendicitis. The patient obtained general anesthesia with intubation. The second laparotomy exploration was conducted on a 1-month-old baby boy with a weight of 3400 grams who suffered bowel low-level obstruction suspect Hirschsprung disease. The patient also obtained general anesthesia with intubation. Discussion The general anesthesia with oral intubation was successfully afforded to both patients for the laparotomy exploration with the preoperative condition under severe thrombocytopenia with receiving platelet transfusion therapy before surgery. Complications of spontaneous bleeding at the time of intubation were not found, no bleeding-difficult-intubation during surgery, and no symptoms of spontaneous bleeding were found. Postoperatively, platelet levels gradually improved. Conclusion: Exploration of laparotomy in patients with severe thrombocytopenia can be carried out with the support of platelet transfusion and providing general anesthesia with oral intubation to patients.

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How well do platelets prevent bleeding?

Hematology ◽

10.1182/hematology.2020000136 ◽

2020 ◽

Vol 2020 (1) ◽

pp. 518-522

Author(s):

Darrell J. Triulzi

Keyword(s):

Platelet Transfusion ◽

Anticoagulation Therapy ◽

Outpatient Setting ◽

Severe Thrombocytopenia ◽

Transfusion Threshold ◽

Spontaneous Bleeding ◽

Risk Of Bleeding ◽

Increased Risk ◽

High Incidence ◽

Platelet Transfusions

Abstract Prophylactic platelet transfusions are used to reduce the risk of spontaneous bleeding in patients with treatment- or disease-related severe thrombocytopenia. A prophylactic platelet-transfusion threshold of <10 × 103/µL has been shown to be safe in stable hematology/oncology patients. A higher threshold and/or larger or more frequent platelet doses may be appropriate for patients with clinical features associated with an increased risk of bleeding such as high fevers, sepsis, disseminated intravascular coagulation, anticoagulation therapy, or splenomegaly. Unique factors in the outpatient setting may support the use of a higher platelet-transfusion threshold and/or dose of platelets. A prophylactic platelet-transfusion strategy has been shown to be associated with a lower risk of bleeding compared with no prophylaxis in adult patients receiving chemotherapy but not for autologous transplant recipients. Despite the use of prophylactic platelet transfusions, a high incidence (50% to 70%) of spontaneous bleeding remains. Using a higher threshold or larger doses of platelets does not change this risk. New approaches to reduce the risk of spontaneous bleeding, including antifibrinolytic therapy, are currently under study.

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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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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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Risk Factors of Hospital-acquired Thrombocytopenia in Toxicological Intensive Care Unit

International Journal of Medical Toxicology and Forensic Medicine ◽

10.32598/ijmtfm.v10i3.32256 ◽

2020 ◽

Vol 10 (3) ◽

pp. 32256-32256

Author(s):

Haleh Talaie ◽

◽

Sayed Masoud Hosseini ◽

Maryam Nazari ◽

Mehdi Salavati Esfahani ◽

...

Keyword(s):

Risk Factors ◽

Intensive Care ◽

Platelet Count ◽

Antihypertensive Drugs ◽

International Normalized Ratio ◽

Severe Thrombocytopenia ◽

Old Patients ◽

Platelet Counts ◽

Hospital Acquired ◽

The Impact

Background: Platelet count is a readily available biomarker predicting disease severity and risk of mortality in the intensive care units (ICU). This study aims to describe the frequency, to assess the risk factors, and to evaluate the impact of thrombocytopenia on patient outcomes in a Toxicological ICU (TICU).Methods: In this prospective observational Cohort study, we enrolled 184 patients admitted to our TICU from October 1st, 2019, to August 23rd, 2020. Mild/moderate and severe thrombocytopenia were defined as at least one platelet counts less than 150×103/μL and 50×103/μL during the ICU stay, respectively.Results: Of 184 enrolled patients, 45.7% had mild to moderate thrombocytopenia and 5.4% had severe thrombocytopenia. Old age (OR: 1.042, 95%CI: 1.01-1.075, P=0.01), male gender (OR: 4.348, 95%CI: 1.33-14.22, P=0.015), increased international normalized ratio (INR) levels (OR: 3.72, 95%CI: 1.15-112, P=0.028), and administration of some medications including heparin (OR: 3.553, 95%CI: 1.11-11.36, P=0.033), antihypertensive drugs (OR: 2.841, 95%CI: 1.081-7.471, P=0.034), linezolid (OR: 13.46, 95%CI: 4.75-38.13, P<0.001), erythromycin (OR: 19.58, 95%CI: 3.23-118.86, P=0.001), and colistin (OR: 10.29, 95% CI 1.44-73.69, P=0.02) were the risk factors of hospital-acquired thrombocytopenia. The outcomes of patients with normal platelet count were significantly better than those who developed thrombocytopenia (P<0.001).Conclusion: We found that thrombocytopenia could develop in almost 50% of patients admitted to TICU, which is associated with poor prognosis. Additionally, the platelet counts should be closely monitored to administer some medications (heparin, antihypertensive drug, and linezolid), especially in old patients.

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Potential Clinical Impact of Inaccurate Automated Platelet Counts in the Setting of Severe Thrombocytopenia

Blood ◽

10.1182/blood.v120.21.3428.3428 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3428-3428

Author(s):

Steven M. Marionneaux ◽

Peter G. Maslak ◽

Nenita Francisco ◽

Virgil Chan ◽

Justin Hanenberg ◽

...

Keyword(s):

Platelet Count ◽

Platelet Transfusion ◽

Statistical Significance ◽

Reference Method ◽

Reference Value ◽

Hematologic Malignancies ◽

Successful Outcome ◽

Severe Thrombocytopenia ◽

Platelet Counts ◽

Number Of Patients

Abstract Abstract 3428 Severe thrombocytopenia is not an uncommon finding in the setting of hematologic malignancies. The key to a successful outcome often lies in the ability to support the patient through periods of cytopenia by adopting an aggressive transfusion strategy for platelets. Therefore, an accurate assessment of the platelet count is of utmost importance particularly as it relates to various levels which “trigger” prophylactic platelet transfusion. However, the accuracy and precision of conventional platelet counting methods have been shown to be suspect in severely thrombocytopenic samples. We investigated the accuracy of several commercial hematology analyzers currently available in clinical practice which use optical, impedance and immunologic platelet determination methods and assessed whether biased results could have an impact on decisions regarding platelet transfusion. Four-hundred three (403) EDTA-anticoagulated samples collected from patients with hematologic malignancies and a platelet count of < 50 × 10e3/uL were selected from the standard workflow processed in the hematology laboratories at MSKCC. Samples were split and tested within 8 hours of collection using optical based methods on the Advia 2120i (Siemens, Tarrytown, NY) and CELL-DYN Sapphire (Abbott Diagnostics, Santa Clara, CA). During the study, an additional analyzer became available, the XE-2100 (Sysmex, Kobe, Japan) which enumerates platelets by impedance and optical technology. One hundred twenty seven (127) of the 403 samples were split and tested by the Sysmex analyzer. Platelet counts from each method were then compared using the CD61 immunoplatelet determination (Abbott, Santa Clara, CA) as the reference value. The CD61 immunoplatelet method was chosen as the reference standard because we found excellent correlation in linear regression between this method and phase microscopy (r =0.99, y = −0.96 + 0.88x; n = 37). Also, the International Counsel for Standardization in Haematology and the International Society for Laboratory Hematology recommend the counting of specifically labelled platelets (CD41, CD61) by flow cytometry as a reference method for the enumeration of platelets. Bland-Altman difference plots were used to visualize the agreement between the reference and test methods and the paired t-test evaluated the statistical significance of the difference between methods. We then compared the number of platelet transfusion indications (at various platelet thresholds) as determined by all methods with potential transfusion decisions made using the reference method. There was a statistically significant positive bias among the optical and impedance methods compared with CD61 enumeration. Using various platelet transfusion decision points, the number of patients who were at risk for under transfusion (platelet count above threshold when reference result is < threshold) ranged from 1–2 % at a threshold of 50k/uL to 30–40 % when the threshold was lowered to 10k/uL. These results highlight the limitations in the accuracy of optical and impedance methods, particularly in the setting of severe thrombocytopenia. Since prophylactic platelet transfusions are by and large based on standard “triggers,” an overestimation of the platelet count may lead to under-transfusion, especially in patients at the highest risk for hemorrhage. Clinicians should be aware of the limitations of automated platelet determinations and consider this when making medical decisions regarding supportive transfusions. Disclosures: Marionneaux: Abbott Diagnostics: Consultancy.

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Thrombocytopenia in 737 adult intensive care unit patients: A real-world study of associated factors, drugs, platelet transfusion, and clinical outcome

SAGE Open Medicine ◽

10.1177/2050312120958908 ◽

2020 ◽

Vol 8 ◽

pp. 205031212095890

Author(s):

Man-ka Zhang ◽

Tian-qi Xu ◽

Xiao-jing Zhang ◽

Zhi-guo Rao ◽

Xiao-xu He ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Bacterial Infection ◽

Platelet Transfusion ◽

Severe Thrombocytopenia ◽

Chi Square ◽

Adult Intensive Care Unit ◽

Factors Associated ◽

Platelet Counts ◽

Chi Square Test

Objective: We aimed to identify and represent factors associated with thrombocytopenia in intensive care unit, especially the pathogens and drugs related to severe and extremely thrombocytopenia. Then, we aim to compare the mortality of platelet transfusion and non-transfusion in patients with different degrees of thrombocytopenia. Methods: We identified all thrombocytopenic patients in intensive care unit by using platelet-specific values and then extracted electronic health records from our Hospital Information System. Data were statistically analyzed with t test, chi-square test, and logistic regression. Results: We found that infections (32.7%) were the most frequent cause associated with thrombocytopenia, followed by sepsis shock (3.93%) and blood loss (2.99%). Meanwhile, antifungals ( p = 0.002) and bacterial infection ( p = 0.037) were associated with severe and extremely severe thrombocytopenia. Finally, we found that the mortality of platelet transfusion and non-transfusion in patients was statistically significant for patients with platelet counts between 30 and 49/nL (χ2 = 9.719, p = 0.002). Conclusion: Infection and sepsis emerged as two primary factors associated with thrombocytopenia in intensive care unit. Meanwhile, antifungals and bacterial infection were associated with platelet counts less than 49/nL. Finally, platelet transfusion may be associated with reduced mortality in patients with platelet counts between 30 and 49/nL.

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Anti-HPA-9bw (Maxa+) Feto-Maternal Alloimmunization and Clinically Severe Neonatal Thrombocytopenia: Difficulties in Diagnosis and Therapy, Report on 12 Cases.

Blood ◽

10.1182/blood.v104.11.2066.2066 ◽

2004 ◽

Vol 104 (11) ◽

pp. 2066-2066

Author(s):

Cecile Kaplan-Gouet ◽

Leendert Porcelijn ◽

Philippe Vanlieferinghen ◽

Eric Julien ◽

Frederic Bianchi ◽

...

Keyword(s):

Monoclonal Antibodies ◽

Platelet Transfusion ◽

False Negative ◽

Poor Response ◽

Laboratory Diagnosis ◽

Severe Thrombocytopenia ◽

Transfusion Therapy ◽

Potential Implication ◽

Negative Results ◽

Neonatal Thrombocytopenia

Abstract Since the first documented case of neonatal thrombocytopenia (NAIT) due to anti HPA-9bw (Maxa+)1, no clinical data report has appeared in the literature. We have conducted a retrospective analysis of the cases referred to the INTS (Paris) in the recent years. This analysis confirms that anti HPA-9bw (Maxa+) NAIT is a clinically severe syndrome which requires prompt diagnosis, in spite of difficulties, and maternal platelet transfusion therapy. This report concerns 8 families (12 neonates) investigated for neonatal thrombocytopenia (initial case included). The diagnosis was performed by genotyping and identification of the maternal alloantibody. The maternal sera reacted with paternal platelets in the MAIPA technique with anti GPIIb-IIIa monoclonal antibodies. No reaction was observed with a standard panel of typed donors and with their own platelets. In 2 families the diagnosis was ascertained retrospectively and the maternal alloantibody not detectable few months after delivery. Platelet genotyping did not show incompatibilities for the known platelet specific alloantigen systems HPA-1 to 11 and HPA-15 when tested in 7 out of 8 families. In the last one, incompatibility was found for HPA-3 without anti HPA-3b maternal alloantibody. As the father was HPA-9bw heterozygous in all the cases, the infant or fetus was genotyped to ascertain the diagnosis. In 10/12 cases, the infant was incompatible with the mother and therefore the diagnosis was straightforward. Four index cases were first-born children. Hemorrhage was present in 5/9 neonates, all but two infants had severe thrombocytopenia at birth, platelet counts<20.109/l and intracranial hemorrhage was documented in 1 patient, otherwise sonograms were normal. When bleeding was present maternal platelet transfusion therapy was given, most of the time because of poor response to random platelet transfusion. In 3 families successive pregnancies were followed up. In one case the fetus was compatible , in another case the 2nd child was moderately affected and in the last case maternal antenatal therapy (IvIgG) was given for fetal thrombocytopenia. Since 1999 we screen for the potential implication of rare antigens in suspected cases of NAIT when there is no other incompatibility. This screening has led us to characterize a new platelet antigen2. Anti HPA-9bw NAIT accounts for ~2% of our confirmed NAIT cases (parental antigen incompatibilities and presence of maternal alloantibodies). Difficulties in laboratory diagnosis for HPA-9bw NAIT mainly relies on the identification of the alloantibody and the paternal heterozygous status for the antigen. We have observed that monoclonal antibodies could interfere with the alloantibody binding in the MAIPA technique leading to false negative results. The diagnosis could only be confirmed after infant genotyping, in our series we have found 1 neonate and 1 fetus compatible with their mother excluding this antigen to be implicated in fetal/neonatal thrombocytopenia. In conclusion, laboratory investigation of a suspected NAIT case should be carried out in a well-versed laboratory for optimal testing. Therapy requires a strict collaboration between clinicians and blood bank services. Appropriate management and antenatal therapy should be considered for successive pregnancies to prevent fetal bleeding.

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PATHOPHYSIOLOGY OF THROMBOCYTOPENIA AND RESULTANT CLINICAL INDICATIONS FOR PLATELET TRANSFUSION

10.1055/s-0038-1643996 ◽

1987 ◽

Author(s):

Sherrill J Slichter

Keyword(s):

Platelet Count ◽

Survival Data ◽

Platelet Transfusion ◽

Disease Process ◽

Bleeding Risk ◽

Underlying Disease ◽

Transfusion Therapy ◽

Platelet Counts ◽

Platelet Survival ◽

Platelet Transfusions

Careful evaluation of platelet survival data in normal individuals and patients with thrombocytopeniasecondary to marrow aplasia has demonstrated that platelets are lost from circulation by two mechanisms a fixed fraction of platelets, amounting to approxi mately 7,100 platelets/ul/day, are lost randomly while the remaining platelets are removed by senescent mechanisms. At platelet counts of <100,000/ul, platelet survival becomes progressively shorter as the fixed platelet loss becomes a proportionately greater fraction of the circulating platelets. Thus, there is a direct relationship between platelet count and platelet survival in thrombocytopenic patients. Therefore, when judging the effectiveness of platelet therapy in thrombocytopenic patients, the influence of platelet count on platelet survival must be considered. As yet, there have been no studies to determine if there are ways to interrupt this fixed platelet loss? whether such therapy might improve platelet support in thrombocyotpenic patients by prolonging platelet survival? or, alternatively, whether such therapy might enhance the bleeding risk if random platelet removal is related to physiologic platelet-endothelial cell interactions.Besides taking into account the effect of thrombocytopenia on the expected response to platelet transfusions, the risk of alloimmunization with platelet transfusion therapy requires a careful assessment of the indications for platelet transfusions for each patient.Based on 51Cr-labeled stool blood loss measurements, we have determined that the bleeding risk is minimal at platelet counts above 10,000 platelets/ul.Only when the platelet count falls to a lower level of 5,000/ul is GI bleeding significantly increased. However, there are certain medications that may enhance the bleeding risk and require platelet transfusions to be given at higher platelet counts.In those patients who are thrombocytopenic, not because of failure of marrow platelet production, but rather because of accelerated platelet removal, indications for platelet transfusions must be adjusted to meet the particular problem. For example, for patients with autoimmune thrombocytopenic purpura, platelet transfusions are rarely indicated (one exception being intracerebral bleeding) because of the rapid rate of platelet removal and because the patients are usually releasing young hyperfunctional platelets from the bone marrow reducing the hemorrhagic risk at any given platelet count. In some patients with consumptive coagulopathies, even though platelet removal is rapid, platelets may have to be provided until specific therapy resolves the underlying disease process causing the platelet consumption. For these patients, increased levels of fibrinogen/fibrin degregation products, as well as various medications they maybe receiving, may produce platelet dysfunction necessitating platelet transfusions at higher platelet levels. Finally, massive transfusion patients may develop a dilution thrombocytopenia requiring platelet transfusions.

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Liver transplantation of a patient with extreme thrombocytopenia - A case report -

Anesthesia and Pain Medicine ◽

10.17085/apm.21006 ◽

2021 ◽

Author(s):

Yena Oh ◽

Seung Yeon Yoo ◽

Gyu-Seong Choi ◽

Gaab Soo Kim

Keyword(s):

Liver Transplantation ◽

Case Report ◽

Liver Disease ◽

Platelet Transfusion ◽

Clinical Signs ◽

Severe Thrombocytopenia ◽

Platelet Counts ◽

Primary Hemostasis ◽

Single Donor ◽

Coagulation Tests

Background: Patients with chronic liver disease (CLD) planned for liver transplantation (LT) often show severe thrombocytopenia, but there is a lack of evidence in deciding the threshold for prophylactic platelet transfusion.Case: A 47-year-old women with acute liver failure was referred for LT. Despite daily transfusion of platelets, platelet counts remained under 10,000/µl. During LT, 2 units of single donor platelets (SDP) were transfused. Although platelet counts remained extremely low (3,000–4,000/µl) no diffuse oozing was observed and the blood loss was 860 ml. Postoperatively, there was no sign of active bleeding or oozing, and the patient received only 1 unit SDP transfusion.Conclusions: CLD patients may have severe thrombocytopenia. However, primary hemostasis may not be significantly hindered due to the existence of rebalanced hemostasis. Prophylactic platelet transfusion in these patients should not be decided based on platelet counts only, but also take other coagulation tests and clinical signs into consideration.

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