Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

Transfusion Support in Hematopoietic Stem Cell Transplantation: A Contemporary Narrative Review

Hematopoietic stem cell transplantation (HSCT) is a cornerstone of modern medical practice, and can only be performed safely and effectively with appropriate transfusion medicine support. Patients undergoing HSCT often develop therapy-related cytopenia, necessitating differing blood product requirements in the pre-, peri-, and post-transplant periods. Moreover, ensuring optimal management for patients alloimmunized to human leukocyte antigens (HLA) and/or red blood cell (RBC) antigens, as well as for patients receiving ABO-incompatible transplants, requires close collaboration with transfusion medicine and blood bank professionals. Finally, as updated transfusion guidelines and novel blood product modifications emerge, the options available to the transplant practitioner continue to expand. Herein, we detail contemporary blood transfusion and transfusion medicine practices for patients undergoing HSCT.

Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH

Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.

Association Between Platelet Levels and 28-Day Mortality in Patients With Sepsis: A Retrospective Analysis of a Large Clinical Database MIMIC-IV

BACKGROUND

This research focused on evaluating the correlation between platelet count and sepsis prognosis, and even the dose-response relationship, in a cohort of American adults.

METHOD

Platelet counts were recorded retrospectively after hospitalization for patients admitted to Beth Israel Deaconess Medical Center's intensive care unit between 2008 and 2019. On admission to the intensive care unit, sepsis patients were divided into four categories based on platelet counts (very low < 50 × 10⁹/L, intermediate-low 50 × 10⁹-100 × 10⁹/L, low 100 × 10⁹-150 × 10⁹/L, and normal ≥ 150 × 10⁹/L). A multivariate Cox proportional risk model was used to calculate the 28-day risk of mortality in sepsis based on baseline platelet counts, and a two-piece linear regression model was used to calculate the threshold effect.

RESULTS

The risk of 28-day septic mortality was nearly 2-fold higher in the platelet very low group when compared to the low group (hazard ratios [HRs], 2.24; 95% confidence interval [CI], 1.92-2.6). Further analysis revealed a curvilinear association between platelets and the sepsis risk of death, with a saturation effect predicted at 100 × 10⁹/L. When platelet counts were below 100 × 10⁹/L, the risk of sepsis 28-day death decreased significantly with increasing platelet count levels (HR, 0.875; 95% CI, 0.84-0.90).

CONCLUSION

When platelet count was less than 100 × 10⁹/L, it was a strong predictor of the potential risk of sepsis death, which is declined by 13% for every 10 × 10⁹/L growth in platelets. When platelet counts reach up to 100 × 10⁹/L, the probability of dying to sepsis within 28 days climbs by 1% for every 10 × 10⁹/L increase in platelet count.

Adverse events associated with donor plateletpheresis: 10 years’ experience from Vojvodina, Serbia

Background/Aim. Plateletpheresis is a medical procedure used for the collection of donor platelets with multiple benefits for patients who will receive apheresis platelets. The procedure takes one hour and is well tolerated by donors. Nevertheless, adverse events may occur during and after the plateletpheresis procedure. The aim was to present one centre experiences in order to determine the incidence and type of adverse events associated with donor plateletpheresis. Methods. A retrospective analysis of adverse events associated with donor plateletpheresis was conducted in the Blood Transfusion Institute of Vojvodina over the period from January 1, 2010 through December 31, 2019. Results. Out of 2073 platelet donors 94.84% were multiple blood donors, predominantly male (98.55%). Adverse events were identified during 180 (8.68%) platelet donations with no statistical significance in occurrence in the first time (10.28%) and repeat donors (8.59%). Mild local reactions related to venous access (42.22%) were the most common adverse events. Generalized symptoms exhibited 16.67% of donors, 26.11% exhibited symptoms related to apheresis - citrate reactions and 15% exhibited those related to other complications. During plateletpheresis occurred 95.55% adverse events and 4.45% after. Conclusion. Donor plateletpheresis is a generally safe procedure, well tolerated by donors. Understanding risk factors for possible occurrence of adverse events provide support for adoption of measures to prevent them.

Thrombocytopenia in intensive care unit patients: A scoping review

BACKGROUND

Thrombocytopenia is frequent in intensive care unit (ICU) patients and may be associated with adverse outcomes. We aimed to assess the incidence, risk factors, and outcomes associated with thrombocytopenia in adult ICU patients.

METHODS

We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included study reports on adult ICU patients with thrombocytopenia and assessed patient-important outcomes, including mortality and health-related quality-of-life.

RESULTS

We included a total of 70 studies comprising a total of 215 098 patients; 57 were cohort studies. The incidence of thrombocytopenia varied from 8 to 56 per 100 admissions (very low quality of evidence). We identified several risk factors including age, sepsis, and higher disease severity (low quality of evidence). Thrombocytopenia was associated with bleeding, use of life support, length of stay in the ICU, and increased mortality (low/very low quality of evidence). Data on platelet transfusion before invasive procedures and transfusion thresholds were limited. No studies assessed the benefits and harms of thromboprophylaxis in ICU patients with thrombocytopenia.

CONCLUSIONS

Thrombocytopenia is common and associated with increased morbidity and mortality in adult ICU patients. Several risk factors for thrombocytopenia exists, but the evidence-base on management strategies, including transfusion thresholds and thromboprophylaxis in ICU patients is very limited.

Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy

IMPORTANCE

Coagulopathy may deter physicians from performing a lumbar puncture.

OBJECTIVE

To determine the risk of spinal hematoma after lumbar puncture in patients with and without coagulopathy.

DESIGN, SETTING, AND PARTICIPANTS

Danish nationwide, population-based cohort study using medical registries to identify persons who underwent lumbar puncture and had cerebrospinal fluid analysis (January 1, 2008-December 31, 2018; followed up through October 30, 2019). Coagulopathy was defined as platelets lower than 150 × 109/L, international normalized ratio (INR) greater than 1.4, or activated partial thromboplastin time (APTT) longer than 39 seconds.

EXPOSURES

Coagulopathy at the time of lumbar puncture.

MAIN OUTCOMES AND MEASURES

Thirty-day risk of spinal hematoma. Risks were provided as numbers and percentages with 95% CIs. Secondary analyses included risks of traumatic lumbar puncture (>300 × 106 erythrocytes/L after excluding patients diagnosed with subarachnoid hemorrhage). Adjusted hazard rate ratios (HRs) were computed using Cox regression models.

RESULTS

A total of 83 711 individual lumbar punctures were identified among 64 730 persons (51% female; median age, 43 years [interquartile range, 22-62 years]) at the time of the procedure. Thrombocytopenia was present in 7875 patients (9%), high INR levels in 1393 (2%), and prolonged APTT in 2604 (3%). Follow-up was complete for more than 99% of the study participants. Overall, spinal hematoma occurred within 30 days for 99 of 49 526 patients (0.20%; 95% CI, 0.16%-0.24%) without coagulopathy vs 24 of 10 371 patients (0.23%; 95% CI, 0.15%-0.34%) with coagulopathy. Independent risk factors for spinal hematoma were male sex (adjusted hazard ratio [HR], 1.72; 95% CI, 1.15-2.56), those aged 41 through 60 years (adjusted HR, 1.96; 95% CI, 1.01-3.81) and those aged 61 through 80 years (adjusted HR, 2.20; 95% CI, 1.12-4.33). Risks did not increase significantly according to overall severity of coagulopathy, in subgroup analyses of severity of coagulopathy by pediatric specialty or medical indication (infection, neurological condition, and hematological malignancy), nor by cumulative number of procedures. Traumatic lumbar punctures occurred more frequently among patients with INR levels of 1.5 to 2.0 (36.8%; 95% CI, 33.3%-40.4%), 2.1 to 2.5 (43.7%; 95% CI, 35.8%-51.8%), and 2.6 to 3.0 (41.9% 95% CI 30.5-53.9) vs those with normal INR (28.2%; 95% CI, 27.7%-28.75%). Traumatic spinal tap occurred more often in patients with an APTT of 40 to 60 seconds (26.3%; 95% CI, 24.2%-28.5%) vs those with normal APTT (21.3%; 95% CI, 20.6%-21.9%) yielding a risk difference of 5.1% (95% CI, 2.9%-7.2%).

CONCLUSIONS AND RELEVANCE

In this Danish cohort study, risk of spinal hematoma following lumbar puncture was 0.20% among patients without coagulopathy and 0.23% among those with coagulopathy. Although these findings may inform decision-making about lumbar puncture by describing rates in this sample, the observed rates may reflect bias due to physicians selecting relatively low-risk patients for lumbar puncture.

Safety of bedside lumbar puncture in adult patients with thrombocytopenia

The risk of lumbar puncture (LP) hemorrhagic complications is believed to be exacerbated by thrombocytopenia, yet evaluations in clinical practice are lacking. We conducted a retrospective cohort study to examine the risk of traumatic tap (TT) and significant hemorrhagic complications in thrombocytopenic patients undergoing bedside LP. Two hundred sixty-two adult patients undergoing initial bedside LP were analyzed. Overall, we observed 37 TTs (14.1%, 95% CI 10.0 to 18.3%). TTs occurred in 11 of 78 LPs performed on patients with thrombocytopenia, compared with 26 of 184 LPs among patients with a normal platelet count (14.1% vs 14.1%; p > 0.99) and 6 of 19 LPs among patients with severe thrombocytopenia compared with 31 of 243 among those without (31.6% vs 12.8%; p = 0.04). For patients with severe thrombocytopenia, the relative risk of TT was 2.5 (95% CI 1.2 to 5.2; p = 0.02). Stratifying this group by operator experience, a higher incidence of TTs was observed in LPs performed by trainees (57.1% vs 15.8%; p = 0.02), an effect which did not reach significance in LPs performed by dedicated procedural operators (16.7% vs 10.8%; p = 0.63). The presence of other bleeding risk factors was not found to be statistically associated with the incidence of TT. There were no significant hemorrhagic complications. TTs occurred significantly more frequently among patients with severe thrombocytopenia, an effect modulated by operator experience. For patients in this higher risk group, LPs should be performed by the most skilled operators available.