Platelet transfusion trigger in difficult patients

HELLP Syndrome and Differential Diagnosis with Other Thrombotic Microangiopathies in Pregnancy

Thrombotic microangiopathies (TMAs) comprise a distinct group of diseases with different manifestations that can occur in both pediatric and adult patients. They can be hereditary or acquired, with subtle onset or a rapidly progressive course, and they are particularly known for their morbidity and mortality. Pregnancy is a high-risk time for the development of several types of thrombotic microangiopathies. The three major syndromes are hemolysis, elevated liver function tests, and low platelets (HELLP); hemolytic uremic syndrome (HUS); and thrombotic thrombocytopenic purpura (TTP). Because of their rarity, clinical information and therapeutic results related to these conditions are often obtained from case reports, small series, registries, and reviews. The collection of individual observations, the evolution of diagnostic laboratories that have identified autoimmune and/or genetic abnormalities using von Willebrand factor post-secretion processing or genetic-functional alterations in the regulation of alternative complement pathways in some of these TMAs, and, most importantly, the introduction of advanced treatments, have enabled the preservation of affected organs and improved survival rates. Although TMAs may show different etiopathogenesis routes, they all show the presence of pathological lesions, which are characterized by endothelial damage and the formation of thrombi rich in platelets at the microvascular level, as a common denominator, and thrombotic damage to microcirculation pathways induces "mechanical" (microangiopathic) hemolytic anemia, the consumption of platelets, and ischemic organ damage. In this review, we highlight the current knowledge about the diagnosis and management of these complications during pregnancy.

Age as a Risk Factor in the Occurrence of Complications during or after Bronchoscopic Lung Biopsy

Introduction: Bronchoscopic lung biopsy (BLB) is a widely used procedure. As the world’s population is ageing, more BLBs are performed for older people with comorbidities. The aim of the study was to investigate if an older age is a risk factor for BLB related complications. Materials and Methods: A prospective study at the Centre of Pulmonology and Allergology of Vilnius University Hospital Santaros klinikos was conducted. Seven hundred and eighty-six patients (male 60.6%), mean age 57 ± 16, who underwent BLB, were included. The complications that occurred due to BLB were evaluated. Bleeding and pneumothorax were classified into I° or II° grades depending on their severity. Potential determinants, which may increase the risk of complications, emphasizing on age, were analyzed. Results: Fifty-seven (7.2%) BLB-related complications occurred. There were 27 (3.4%) pneumothoraxes, and 19 (70%) of them required thoracic drainage. Thirty (3.8%) bleeding complications occurred, and four (16%) of them were severe. Higher rates of bleeding were found in the age group ≥65 years, p = 0.001. The risk of bleeding in older patients was 3.2 times higher (95% CI 1.51–6.87). Conclusions: Older age is related to a higher incidence of mild bleeding during BLB. However, the risk of life-threatening complications is low despite the age, and older age should not be considered as a contraindication for the procedure if needed.

Dentoalveolar Procedures in Immune Thrombocytopenia; Systematic Review and an Institutional Guideline

Background  Dentoalveolar procedures in immune thrombocytopenia (ITP) pose a risk of bleeding due to thrombocytopenia and infection due to immunosuppressive treatments. We aimed to systematically review the safety and management of dentoalveolar procedures in ITP patients to create practical recommendations.

Methods  PubMed, Embase, Cochrane, and Cinahl were searched for original studies on dentoalveolar procedures in primary ITP patients. We recorded bleeding- and infection-related outcomes and therapeutic strategies. Clinically relevant bleeding was defined as needing medical attention.

Results  Seventeen articles were included, of which 12 case reports/series. Overall, the quality of the available evidence was poor. Outcomes and administered therapies (including hemostatic therapies and prophylactic antibiotics) were not systematically reported. At least 73 dentoalveolar procedures in 49 ITP patients were described. The range of the preoperative platelet count was 2 to 412 × 10 ⁹ /L. Two clinically relevant bleedings (2%) were reported in the same patient of which one was life-threatening. Strategies used to minimize the risk of bleeding were heterogeneous and included therapies to increase platelet count, antifibrinolytics, local measures, and minimally invasive techniques. Reports on the occurrence of bleedings due to anesthetics or infection were lacking.

Conclusion  Based on alarmingly limited data, clinically relevant bleedings and infections after dentoalveolar procedures in ITP patients seem rare. Awaiting prospective and controlled studies to further evaluate these risks and the efficacy of therapeutic interventions, we provided our institutional guideline to guide the management of dentoalveolar procedures in ITP patients.

Post-transfusion platelet responses in critically ill cancer patients with hypoproliferative thrombocytopenia

BACKGROUND

Platelet transfusion is aimed at increasing platelet counts to prevent or treat bleeding. Critically ill cancer patients with hypoproliferative thrombocytopenia are high consumers of blood products. We herein described their post-transfusion platelet responses in the intensive care unit (ICU) and analyzed the determinants of poor post-transfusion increments.

STUDY DESIGN AND METHODS

This was a single-center 9-year (2009-2017) retrospective observational study. Patients with malignancies and presumed or proven hypoproliferative thrombocytopenia who had received at least one platelet transfusion in the ICU were included. Poor post-transfusion platelet increments were defined as body surface-adjusted corrected count increment (CCI) <7, or alternatively as weight-adjusted platelet transfusion recovery (PTR) <0.2. Patients were deemed refractory to platelet transfusions when two consecutive ABO-compatible transfusions resulted in poor platelet increments.

RESULTS

A total of 1470 platelet transfusions received by 326 patients were analyzed. Indications for platelet transfusions were distributed into prophylactic (44.5%), peri-procedural (18.1%) and therapeutic (37.4%). Regardless of indications, 54.6% and 55.4% of transfusion episodes were associated with a CCI <7 or a PTR <0.2. Factors independently associated with poor post-transfusion increments were lower body mass index, spleen enlargement, concurrent severity of clinical condition, fever ≥39°C, antibiotic therapy and increased storage duration of platelet concentrates. Eventually, 48 patients developed refractoriness to platelet transfusion, which was associated increased incidence of bleeding events.

CONCLUSION

Platelet transfusions are often associated with poor increments in critically ill cancer patients with hypoproliferative thrombocytopenia. The findings suggest amenable interventions to improve the platelet transfusion practices in this setting.

A systematic approach to the management of massive hemoptysis

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.

Endoscopic submucosal dissection for early gastric cancer in a patient with myelodysplastic syndrome

Endoscopic submucosal dissection (ESD) has been successfully performed in thrombocytopenic conditions such as in patients with liver cirrhosis but successful ESD for early gastric cancer (EGC) in hematologic diseases has rarely been reported. A 52-year-old male patient, who had previously been diagnosed with myelodysplastic syndrome 2 years ago, was admitted to our hospital for ESD of EGC. ESD was performed successfully in this patient after platelet concentrates transfusion on the day of ESD. ESD might be an option for the treatment of EGC in thrombocytopenia due to hematologic diseases when optimal supportive managements are applied.

Hematology in palliative medicine

Advanced cancer and life-limiting chronic nonmalignant diseases are associated with a number of hematological problems. Anemia and coagulation disorders, principally venous thrombosis and thrombocytopenia, are most commonly observed. Patients undergoing chemotherapy and bone marrow transplant have unique problems that include neutropenias and chemotherapy-induced drug toxicities, which will not be covered in this article.

Thrombocytopenia in Critical Care Patients

Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.

Safety of endoscopic interventions in patients with thrombocytopenia

BACKGROUND

The risk of endoscopic interventions in thrombocytopenia has received little attention in the medical literature.

OBJECTIVE

The aim of this study was to assess the safety of endoscopic interventions including evaluation of GI bleeding (GIB) in patients with thrombocytopenia.

DESIGN AND SETTING

Retrospective study, tertiary oncology center.

PATIENTS AND INTERVENTION

Review of consecutive endoscopies with preprocedure platelet counts (PCs) of 75 × 10(3)/μL or lower.

MAIN OUTCOME MEASUREMENTS

Risk of bleeding with routine endoscopic interventions and transfusion requirement after evaluation of GIB.

RESULTS

A total of 617 (351 upper, 266 lower [90 colonoscopies]) endoscopies were performed in 395 patients. Forceps-biopsy specimens were obtained in 398 endoscopies (mean ± standard deviation [SD] PC: 38.21 ± 11.7 × 10(3)/μL) and 45 polypectomies were performed in 17 endoscopies (mean ± SD PC: 39.65 ± 8.53 × 10(3)/μL). The risk of bleeding was 1.5% (6 of 398 endoscopies) at the biopsy site and 4% (2 of 45 polypectomies) at the polypectomy site. Active GIB (mean ± SD PC: 32.85 ± 4.0 × 10(3)/μL) was observed in 68 (11% of 617) endoscopies and intervention (mean ± SD PC: 33.68 ± 4.6 × 10(3)/μL) was performed in 41 procedures. Together, angiodysplasias and ulcers were the most common etiology (51.2% of 41). Hemostasis was achieved in 39 (95.1% of 41) procedures. Comparison of blood transfusions ± 3 days of successful therapy showed a 52% reduction (P < .001). By multivariate analysis, a higher aggregate blood transfusion 3 days preceding endoscopy (odds ratio 1.32; 95% confidence interval, 1.16-1.50; P < .001) predicted endoscopic findings of active GIB.

LIMITATIONS

Retrospective design, single center.

CONCLUSIONS

In the largest endoscopic experience reported in thrombocytopenic patients (Common Terminology Criteria for Adverse Events grade 3 or lower), bleeding caused by standard forceps biopsy and polypectomy (≤10 mm) was minor and easily controlled. Endoscopic therapy for GIB is safe and significantly reduces the packed red blood cell requirement and should be considered in patients with thrombocytopenia in the setting of an appropriate transfusion strategy.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Point of care devices for assessing bleeding and coagulation in the trauma patient

Severe trauma is associated with bleeding, coagulopathy, and transfusion of blood and blood products, all contributing to higher rates of morbidity and mortality. The aim of this review is to focus on point-of-care devices to monitor coagulation in trauma. Close monitoring of bleeding and coagulation as well as platelet function in trauma patients allows goal-directed transfusion and an optimization of the patient's coagulation, reduces the exposure to blood products, reduces costs, and probably improves clinical outcome. Noninvasive hemoglobin measurements are not to be used in trauma patients due to a lack in specificity and sensitivity.

Transfusion medicine problems and solutions for the pediatric hematologist/oncologist

Blood component transfusion is an integral part of the care of children with oncologic and hematologic conditions. The complexity of transfusion medicine may however lead to challenges for pediatric hematologists/oncologists. In this review, three commonly encountered areas of transfusion medicine are explored. The approach to the investigation and management of suspected platelet refractoriness is reviewed. The unique transfusion related challenges encountered by children undergoing stem cell transplantation are also discussed. Finally, issues arising out of the care of children with hemoglobinopathies are explored, with an emphasis on the incidence of allo- and autoimmunization.

Efficacy and safety of eltrombopag in Japanese patients with chronic liver disease and thrombocytopenia: a randomized, open-label, phase II study

BACKGROUND

Eltrombopag is an oral thrombopoietin receptor agonist that stimulates thrombopoiesis and shows higher exposure in East Asian patients than in non-Asian patients. We evaluated the pharmacokinetics, efficacy, and safety of eltrombopag in Japanese patients with thrombocytopenia associated with chronic liver disease (CLD).

METHODS

Thirty-eight patients with CLD and thrombocytopenia (platelets <50,000/μL) were enrolled in this phase II, open-label, dose-ranging study that consisted of 2 parts. In the first part, 12 patients received 12.5 mg of eltrombopag once daily for 2 weeks. After the evaluation of safety, 26 patients were randomly assigned to receive either 25 or 37.5 mg of eltrombopag once daily for 2 weeks in the second part.

RESULTS

Pharmacokinetics showed that the geometric means of the maximum plasma concentration (C(max)) and the area under the curve (AUC) in the 12.5 mg group were 3,413 ng/mL and 65,236 ng h/mL, respectively. At week 2, the mean increases from baseline in platelet counts were 24,800, 54,000, and 60,000/μL in the 12.5, 25, and 37.5 mg groups, respectively. The median platelet counts increased within 2 weeks of the beginning of administration in all groups, and remained at the same level throughout the 2-week post-treatment period in the 12.5 mg group, whereas the platelet counts peaked a week after the last treatment in both the 25 and 37.5 mg groups. Most adverse events reported were grade 1 or 2; 2 patients in the 37.5 mg group had drug-related serious adverse events.

CONCLUSIONS

Eltrombopag ameliorated thrombocytopenia in Japanese patients with CLD and thrombocytopenia. The recommended dose for these patients is 25 mg daily for 2 weeks.

Incidence of bleeding following invasive procedures in patients with thrombocytopenia and advanced liver disease

BACKGROUND & AIMS

Patients with advanced liver disease often undergo invasive procedures, so the combination of thrombocytopenia, coagulopathy, and bleeding should be carefully assessed. We evaluated the prevalence of thrombocytopenia in a series of patients with liver cirrhosis who were being evaluated for orthotopic liver transplantation (OLT) and determined the number of invasive procedures and procedure-related incidences of bleeding in patients with thrombocytopenia.

METHODS

We studied 121 consecutive patients who were being evaluated for OLT. Thrombocytopenia was defined as a platelet count <150,000/μL and severe thrombocytopenia as a platelet count <75,000/μL. The presence of significant coagulopathy was defined as an international normalized ratio >1.5. Invasive procedures and incidences of procedure-related bleeding were recorded for each patient.

RESULTS

The prevalence of thrombocytopenia and severe thrombocytopenia were 84% and 51%, respectively. Among the 102 thrombocytopenic patients, 50 (49%) underwent an invasive procedure (32 with severe thrombocytopenia; 64%). Bleeding occurred in 10 of the patients who underwent an invasive procedure (20%). Among the 50 patients who underwent invasive procedure, 32 had severe thrombocytopenia and 18 had moderate thrombocytopenia. Bleeding occurred in 10 of the 32 patients (31%) with severe thrombocytopenia and in none of those with moderate thrombocytopenia. There was no difference in prevalence of significant coagulopathy between patients with severe thrombocytopenia who underwent invasive procedure and bled (3/10; 30%) and those who did not bleed (10/22; 45%).

CONCLUSIONS

Thrombocytopenia has a high prevalence among patients with advanced liver disease. Bleeding related to invasive procedures occurs most frequently in patients with severe thrombocytopenia, whereas significant coagulopathy does not seem to be associated with bleeding.

Hemostatic and hemorrhagic problems in neurosurgical patients

BACKGROUND

Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years.

METHOD

The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery.

FINDINGS

According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided.

CONCLUSIONS

Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.

Review article: thrombocytopenia in chronic liver disease

BACKGROUND

Thrombocytopenia is a common finding in advanced liver disease. It is predominantly a result of portal hypertension and platelet sequestration in the enlarged spleen, but other mechanisms may contribute. The liver is the site of thrombopoietin (TPO) synthesis, a hormone that leads to proliferation and differentiation of megakaryocytes and platelet formation. Reduced TPO production further reduces measurable serum platelet counts.

AIM

This paper describes the scope of thrombocytopenia in chronic liver disease and assesses the clinical impact in this patient population.

METHODS

A medline review of the literature was performed pertaining to thrombocytopenia and advanced liver disease. This data is compiled into a review of the impact of low platelets in liver disease.

RESULTS

The incidence of thrombocytopenia, its impact on clinical decision making and the use of platelet transfusions are addressed. Emerging novel therapeutics for thrombocytopenia is also discussed.

CONCLUSIONS

Thrombocytopenia is a common and challenging clinical disorder in patients with chronic liver disease. New therapeutic options are needed to safely increase platelet counts prior to invasive medical procedures as well as to counteract therapies that further exacerbate low platelets, such as interferon. An ideal compound would be orally available and safe, with rapid onset of action.

A systematic review and survey of the management of unexpected neonatal alloimmune thrombocytopenia

BACKGROUND

Unexpected neonatal alloimmune thrombocytopenia (NAIT) may have devastating consequences and its management is challenging. To design future trials, evidence from the literature and existing best practice need review.

STUDY DESIGN AND METHODS

This study was a cross-sectional survey of neonatal units in Germany and Canada to determine management strategies of NAIT and a systematic search for randomized controlled trials (RCTs).

RESULTS

Management of NAIT differs substantially between countries with regard to platelet (PLT) thresholds for screening, initiation of therapy, and treatment. Seventy-seven percent of Canadian physicians versus 68 percent of German physicians screen preterm and term infants, at a PLT threshold of 30 x 10(9) to 100 x 10(9) per L. In preterm infants, 60 percent of Canadian neonatologists commence treatment at a PLT count of between 30 x 10(9) and 50 x 10(9) per L. In Germany 32 percent of the physicians start treatment at this level and 25 percent use a threshold of between 10 x 10(9) and 20 x 10(9) per L. In term infants, 6 percent of the Canadian physicians and 16 percent of the German physicians use even lower treatment triggers of between 5 x 10(9) and 10 x 10(9) per L. In the presence of bleeding, 61 percent of German physicians await the arrival of antigen-negative PLTs, while 64 percent of Canadian neonatologists prefer intravenous immunoglobulin or random-donor PLTs (81%). Maternal PLTs are utilized by 31 percent of physicians in both countries. No RCTs were identified.

CONCLUSION

In the absence of RCTs, management of unexpected NAIT differs between countries. Clinicians and transfusion services may use the results of our study to develop collaborative protocols, redefine preferred hospitalwide strategies, and design future controlled trials.

Blood transfusions in children: a multi-institutional analysis of practices and complications

BACKGROUND

Blood product transfusions are a valuable health-care resource. Guidelines for transfusion exist, but variability in their application, particularly in children, remains. The risk factors that threaten transfusion safety are well established, but because their occurrence in children is rare, single-institution studies have limited utility in determining the rates of occurrence. An epidemiologic approach that investigates blood transfusions in hospitalized children may help improve our understanding of transfused blood products in this vulnerable population.

STUDY DESIGN AND METHODS

This was a nonconcurrent cohort study of pediatric patients not more than 18 years of age hospitalized from 2001 to 2003 at 35 academic children's hospitals that are members of the Pediatric Health Information System (PHIS).

RESULTS

A total of 51,720 (4.8%) pediatric patients received blood product transfusions during the study period. Red blood cells (n = 44,632) and platelets (n = 14,274) were the two most frequently transfused products. The rate of transfusions was highest among children with neutropenia, agranulocytosis, and sickle cell crisis. Asian and American Indian patients had important differences in the rate of blood transfusions and their complications. Resource use in terms of length of stay and costs were higher in patients who received transfusion. Of those patients who received transfusions, 492 (0.95%) experienced a complication from the administered blood product. This accounted for a rate of complications of 10.7 per 1,000 units transfused.

CONCLUSIONS

The administration of blood products to children is a common practice in academic children's hospitals. Complications associated with these transfused products are rare.

Discrepancy between impedance and immunofluorescence platelet counting has implications for clinical decision making in patients with idiopathic thrombocytopenia purpura

This study investigated whether differences occur between the impedance and immunofluorescence methods for platelet quantification in idiopathic thrombocytopenia purpura (ITP). Immunofluorescence gave a platelet count >50% higher than the impedance test in 9/35 (26%) patients, of which 4/35 (11%) were >100% higher. The clinical severity of thrombocytopenia was changed as a result of the immunofluorescence test in 14/35 (40%) patients. Neither mean platelet volume nor platelet distribution width predicted impedance/immunofluorescence method discrepancy. It is suggested that immunofluorescence platelet counts should be performed on all ITP patients when the implementation of a therapeutic or diagnostic intervention is being considered.

Effects of storage-induced platelet microparticles on the initiation and propagation phase of blood coagulation

Platelets shed microparticles, which support haemostasis via adherence to the damaged vasculature and by promoting blood coagulation. We investigated mechanisms through which storage-induced microparticles might support blood coagulation. Flow cytometry was used to determine microparticle number, cellular origin and surface expression of tissue factor (TF), procoagulant phosphatidylserine (PtdSer) and glycoprotein (GP) Ib-alpha. The influence of microparticles on initiation and propagation of coagulation were examined in activated factor X (factor Xa; FXa) and thrombin generation assays and compared with that of synthetic phospholipids. About 75% of microparticles were platelet derived and their number significantly increased during storage of platelet concentrates. About 10% of the microparticles expressed functionally active TF, as measured in a FXa generation assay. However, TF-driven thrombin generation was only found in plasma in which tissue factor pathway inhibitor (TFPI) was neutralised, suggesting that microparticle-associated TF in platelet concentrates is of minor importance. Furthermore, 60% of all microparticles expressed PtdSer. In comparison with synthetic procoagulant phospholipids, the maximal rate of thrombin formation in TF-activated plasma was 15-fold higher when platelet-free plasma was titrated with microparticles. This difference could be attributed to the ability of microparticles to propagate thrombin generation by thrombin-activated FXI. Collectively, our findings indicate a role of microparticles in supporting haemostasis by enhancement of the propagation phase of blood coagulation.

Contraindications and safety of transbronchial lung biopsy via flexible bronchoscopy. A survey of pulmonologists and review of the literature

BACKGROUND

Transbronchial lung biopsy (TBLB) via flexible bronchoscopy is a common procedure performed by pulmonologists. Limited scientific data exist concerning the risk of this procedure in patients with conditions that may adversely affect the rate of procedural complications.

OBJECTIVES

To evaluate the current practice pattern and attitude of pulmonologists toward the performance of TBLB in the presence of high-risk conditions.

METHODS

A survey was constructed and distributed at the American College of Chest Physicians annual meeting, held in Philadelphia, USA, in November of 2001.

RESULTS

A total of 227 surveys were distributed with a return of 158 (69.6%). Anticoagulation medications are temporarily held prior to TBLB by the majority of our survey respondents (98.7% for intravenous heparin, 90.5% for warfarin, and 87.3% for low-molecular-weight heparin). Medications with effect on platelet function are held by fewer pulmonologists. There is a wide variation in the pulmonologists' perception of the risk of performing TBLB when certain medical conditions coexist: pulmonary hypertension [absolute contraindication (AC), 28.7%; relative contraindication (RC) 58.6%], superior vena cava syndrome (AC 19.6%, RC 51%), mechanical ventilation (AC 17.8%, RC 58.6%) and lung cavity/abscess (AC 7%, RC 44.9%). A significant percentage of pulmonologists (55%) do not regard an elevated serum creatinine at any level as AC to TBLB. Thirty-eight percent of the survey participants administer desmopressin prior to TBLB in uremic patients to prevent excessive bleeding.

CONCLUSIONS

Prior to performing bronchoscopic TBLB, the majority of pulmonologists temporarily holds anticoagulation medications. However, there is a lack of agreement in relation to perceived contraindications and safety of TBLB.

[Indications for use of labile blood products and the physiology of blood transfusion in medicine. The French Agency for the Health Safety of Health Products]

This article presents the French national recommendations for the use of blood products in medicine.

Platelet transfusions in infants with necrotizing enterocolitis do not lower mortality but may increase morbidity

OBJECTIVE

Necrotizing enterocolitis (NEC), a serious multisystemic inflammatory disease most commonly seen in premature neonates, is often associated with thrombocytopenia. Infants with severe forms of NEC commonly have platelet counts of less than 50,000/mm(3), occasionally less than 10,000/mm(3). Despite an absence of data to support the practice, platelet transfusions are commonly used to maintain a certain arbitrary platelet count in an effort to prevent bleeding. As platelet transfusions contain a variety of bioactive factors including pro-inflammatory cytokines, we hypothesized that a higher number and volume of platelet transfusions would not be associated with an improvement in mortality or morbidity.

STUDY DESIGN

A retrospective cohort analysis was conducted of the medical records of all infants between 1997 and 2001 with Bell's Stage 2 or 3 NEC associated with platelet counts of <100,000/mm(3). The medical records were evaluated for the following variables: platelet counts, number and volume of platelet transfusions, symptoms of bleeding, and hospital course. Mortality and development of short bowel syndrome and/or cholestasis were correlated to the total number and volume (total ml and ml/kg) of platelet transfusions. Differences between the outcome groups were compared using the independent t-test, Fisher's exact test and Mann-Whitney tests.

RESULTS

A total of 46 infants met the study criteria (gestational age 28+/-4 weeks and birth weight 1166+/-756 g, mean+/-SD). There were a total of 406 platelet transfusions administered to the study population. Of these, 151 (37.2%) were given in the presence of active bleeding, with 62% of these resulting in the cessation of bleeding within 24 hours. Other listed indications for platelet transfusions were hypovolemia and severe thrombocytopenia. On analysis of the entire cohort, there was no statistical improvement in either mortality or morbidity (short bowel syndrome and cholestasis) with greater number and/or volume of platelet transfusions. Furthermore, we found that infants who developed short bowel syndrome and/or cholestasis had been given a significantly higher number and volume of platelet transfusions when compared to those who did not have these adverse outcomes [median (minimum - maximum) - number of transfusions : 9 (0 to 33) vs 1.5 (0 to 20), p=0.010; volume of transfusions (ml/kg): 121.5 (0 to 476.6) vs 33.2 (0 to 224.3), p=0.013].

CONCLUSION

This retrospective analysis suggests that greater number and volume of platelet transfusions in infants with necrotizing enterocolitis are associated with greater morbidity in the form of short bowel syndrome and/or cholestasis without the benefit of lower mortality.

Placement of Intracranial Pressure Monitors: Are ???Normal??? Coagulation Parameters Necessary?

INTRODUCTION

Patients with head injuries frequently have abnormal coagulation studies. Monitoring intracranial pressure (ICP) in head injured patients is common practice, but no best practice guidelines exist for coagulation parameters for ICP monitor placement.

PURPOSE

To test the hypothesis that hemorrhagic complication rates from ICP monitor placement are low and that the use of FFP to correct coagulation parameters to "normal" is not indicated.

METHODS

Retrospective review of all patients admitted to a Level I trauma center over a 3 year period, who underwent fiberoptic intraparenchymal ICP monitoring was undertaken. Inclusion criteria were coagulation studies (prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR), platelet count) before ICP monitor placement and head CT scans to assess for hemorrhage before and after monitor placement. Data collected included age, Glasgow coma score (GCS), head region abbreviated injury score (H_AIS), time to ICP monitor placement, complications and outcomes.

RESULTS

From 8/1/00 through 7/31/03, 5163 trauma patients were admitted, and 157 met inclusion criteria. Patients were stratified by INR, at the time of ICP placement as normal (0.8-1.2, 103 patients), borderline (1.3-1.6, 42 patients) and increased (>/=1.7, 12 patients). There was no difference between the groups in age, gender or H_AIS. Twenty two patients had component therapy to correct coagulopathy before ICP insertion, but 10 had INRs in the borderline group and 12 remained with INRs >/=1.7. Eleven patients had platelet counts 50,000-100,000 at ICP monitor placement, despite platelet transfusions. Time from admission to ICP monitor placement was significantly longer in patients who received component therapy (19.2 +/- 19.7 hours versus 8.8 +/- 13.9 hours, p < 0.002). Three patients had clinically insignificant, petechial hemorrhages (1.9%); one in each group, with INRs of 1.2, 1.3, and 2.5, respectively.

CONCLUSIONS

In patients with INR </=1.6, hemorrhagic complications after ICP monitor placement were infrequent. The use of FFP to "normalize" INR below this threshold is not supported by this data and delays monitor placement.

Anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia

PURPOSE

To describe the anesthetic management of Cesarean delivery in a patient with hypoplastic anemia and severe pre-eclampsia.

CLINICAL FEATURES

A 28-yr-old parturient with a history of thrombocytopenia was admitted with signs of pre-eclampsia (blood pressure of 140/90 mmHg, heavy proteinuria and moderate bilateral ankle edema) at 25 weeks of gestation. Laboratory studies revealed pancy-topenia (hemoglobin 6.4 g.dL(-1), white cell count 3.43 x 10(9).L(-1), platelet count 20 x 10(9).L(-1)) and bone marrow biopsy showed hypoplastic anemia. As pre-eclampsia worsened, a Cesarean delivery was performed at 27 weeks with prophylactic platelet transfusion and meticulous blood pressure control. The procedure was uneventful, conducted under general anesthesia with an estimated blood loss of around 600 mL and a live female baby was delivered. Postoperatively her blood pressure and neurological symptoms improved but thrombocytopenia remained at discharge.

CONCLUSIONS

Hypoplastic anemia is rare in pregnancy but it poses an increased risk for both mother and fetus. The mother is at risk of life-threatening episodes of bleeding and infection and a multidisciplinary team approach (obstetrician, anesthesiologist, hematologist and pediatrician) is essential. An accurate assessment of the hematological condition should be made and abnormalities corrected before surgery. Regional anesthesia may not be possible in this circumstance.

Erythropoietin increases platelet reactivity and platelet counts in patients with alcoholic liver cirrhosis: a randomized, double-blind, placebo-controlled study

BACKGROUND

Patients with liver cirrhosis have a complex haemostasis disturbance including thrombocytopenia and abnormal bleeding time. Erythropoietin is the primary stimulator for erythrocyte production and also induces megakaryocyte formation. In healthy men erythropoietin increased platelet count and platelet reactivity.

AIM

As patients with liver cirrhosis often undergo invasive procedures, we were interested to study whether erythropoietin could improve platelet function in addition to thrombocytopenia.

METHODS

In total, 22 thrombocytopenic (platelet counts < 120 g/L) patients with alcoholic liver cirrhosis received either 100 IE/kg erythropoietin or placebo on days 1, 3 and 5 in a 2:1 randomized, placebo-controlled double-blind fashion. Platelet counts and platelet reactivity (activator-stimulated expression of P-selectin on platelets measured by flow cytometry) were determined on study days 1, 3, 5 and 9.

RESULTS

Median platelet count was 80 g/L which is borderline for major elective surgical interventions. Baseline values were not different between groups (P > 0.05). Treatment with erythropoietin increased platelet count by 25% (P = 0.01) and platelet reactivity twofold (P < 0.01) vs. baseline. The increase in platelet count vs. baseline was more pronounced in patients with platelet counts <80 g/L. No significant effect was observed in the placebo group.

CONCLUSIONS

Treatment with erythropoietin significantly increased platelet counts and platelet reactivity in patients with alcoholic liver cirrhosis. Preoperative treatment with erythropoietin is therefore expected to yield higher platelet levels and better platelet function.

Post-splenectomy thrombocytopenia: implications for regional analgesia

Hospital computerised records were reviewed to identify patients who had undergone splenectomy, then chart their platelet count before and for the 5 days after the operation. A pre-operative platelet count less than 100 x 10(9).l-1 occurred in 66% of leukaemia (n = 35), 56% of lymphoma (n = 41) and 5% of solid tumour (n = 39) patients. Platelet supplementation prior to epidural catheter insertion may reduce the risks of spinal bleeding. However, accidental catheter removal during a postoperative period of thrombocytopenia may lead to formation of an epidural haematoma. The lowest postoperative platelet count was less than 100 x 10(9).l-1 in 66% of leukaemia, 27% of lymphoma and 13% of solid tumour patients. Platelet counts varied considerably, so predicting an individual patient's postoperative nadir from the pre-operative count would be impossible. Consequently, placement of an epidural catheter in many of these patients could expose them to an increased risk of spinal bleeding if the catheter is removed accidentally.