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van der Staaij H, Hooiveld NMA, Caram-Deelder C, Fustolo-Gunnink SF, Fijnvandraat K, Steggerda SJ, de Vries LS, van der Bom JG, Lopriore E. Most major bleeds in preterm infants occur in the absence of severe thrombocytopenia: an observational cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326959. [PMID: 39009429 DOI: 10.1136/archdischild-2024-326959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE To describe the incidence of major bleeds according to different platelet counts in very preterm infants, and to explore whether this association is influenced by other risk factors for bleeding. DESIGN Observational cohort study. SETTING A Dutch tertiary care neonatal intensive care unit. PATIENTS All consecutive infants with a gestational age at birth <32 weeks admitted between January 2004 and July 2022. EXPOSURE Infants were stratified into nine groups based on their nadir platelet count (×109/L) during admission (<10, 10-24, 25-49, 50-99, 100-149, 150-199, 200-249, 250-299 and ≥300), measured before the diagnosis of a major bleed and before any platelet transfusion was administered. MAIN OUTCOME MEASURE Incidence of major bleeds during admission. Logistic regression analysis was used to quantify the relationship between nadir platelet count and incidence of major bleeds. RESULTS Among 2772 included infants, 224 (8%) developed a major bleed. Of the infants with a major bleed, 92% (206/224) had a nadir platelet count ≥50×109/L. The incidence of major bleeds was 8% among infants with and without severe thrombocytopenia (platelet count <50×109/L), 18/231 (95% CI 5 to 12) and 206/2541 (95% CI 7 to 9), respectively. Similarly, after adjustment for measured confounders, there was no notable association between nadir platelet counts below versus above 50×109/L and the occurrence of major bleeds (OR 1.09, 95% CI 0.61 to 1.94). CONCLUSION In very preterm infants, the vast majority of major bleeds occur in infants without severe thrombocytopenia.
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Affiliation(s)
- Hilde van der Staaij
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nadine M A Hooiveld
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Suzanne F Fustolo-Gunnink
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Institute for Advanced Study, University of Amsterdam, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Sanquin Research & Lab Services, Sanquin Blood Supply Foundation, Amsterdam, The Netherlands
- Department of Paediatric Haematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sylke J Steggerda
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Linda S de Vries
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Enrico Lopriore
- Department of Paediatrics, Division of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
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2
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Maier CL, Stanworth SJ, Sola-Visner M, Kor D, Mast AE, Fasano R, Josephson CD, Triulzi DJ, Nellis ME. Prophylactic Platelet Transfusion: Is There Evidence of Benefit, Harm, or No Effect? Transfus Med Rev 2023; 37:150751. [PMID: 37599188 DOI: 10.1016/j.tmrv.2023.150751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 08/22/2023]
Abstract
The optimal use of prophylactic platelet transfusion remains uncertain in a number of clinical scenarios. Platelet count thresholds have been established in patients with hematologic malignancies, yet thresholds backed by scientific data are limited or do not exist for many patient populations. Clinical scenarios involving transfusion thresholds for thrombocytopenic patients with critical illness, need for surgery or invasive procedures, or those involving specials populations like children and neonates, lack clear evidence for discerning favorable outcomes without undue risk related to platelet transfusion. In addition, while prophylactic platelet transfusions are administered with the goal of enhancing hemostasis, increasing evidence supports critical nonhemostatic roles for platelets related to innate and adaptive immunity, inflammation, and angiogenesis, which may impact patient responses and outcomes. Here we review several recent studies conducted in adult or pediatric patients that highlight the limitations in our current understanding of prophylactic platelet transfusion. Together, these studies underscore the need for additional research, especially in the form of robust randomized clinical trials and integrating additional parameters beyond the platelet count. Future research at the basic, translational, and clinical levels will best define the optimal role for prophylactic transfusion across the lifespan and its broader impact on health and disease.
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Affiliation(s)
- Cheryl L Maier
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | - Simon J Stanworth
- NHSBT; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine, University of Oxford; Oxford, United Kingdom
| | | | - Daryl Kor
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Allan E Mast
- Department of Cell Biology, Neurobiology and Anatomy, Versiti Blood Center of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ross Fasano
- Center for Transfusion Medicine and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Cassandra D Josephson
- Department of Oncology, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Darrell J Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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3
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Kurita N, Nishikii H, Maruyama Y, Suehara Y, Hattori K, Sakamoto T, Kato T, Yokoyama Y, Obara N, Maruo K, Ohigashi T, Yamaguchi H, Iwamoto T, Minohara H, Matsuoka R, Hashimoto K, Sakata-Yanagimoto M, Chiba S. Safety of romiplostim administered immediately after cord-blood transplantation: a phase 1 trial. Ann Hematol 2023; 102:2895-2902. [PMID: 37589942 DOI: 10.1007/s00277-023-05410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
Graft failure and delayed hematopoietic recovery are the major limitations of cord-blood transplantation (CBT). Romiplostim, a thrombopoietin-receptor agonist, promotes megakaryopoiesis and multilineage hematopoiesis in aplastic anemia. The decreased number of hematopoietic stem cells in the early phase after CBT and aplastic anemia share certain characteristics. Therefore, we hypothesized that romiplostim administration immediately after CBT may promote multilineage hematopoietic recovery. We investigated the safety and preliminary efficacy of administering romiplostim a day after CBT. This phase 1 dose-escalation study included six adults with hematologic malignancies in remission. Romiplostim was administered subcutaneously within 7 days after single-unit CBT, initially at doses of 5 µg/kg or 10 µg/kg in three patients, then once a week for 14 weeks or until platelet recovery. The maximum dose was 20 µg/kg. The median number of romiplostim administrations was 6 (range, 3-15). Romiplostim-related adverse events included bone pain (3/6) and injection site reaction (1/6). Non-hematological grade ≥ 3 toxicities were observed in four patients; febrile neutropenia was the most common (4/6). All patients achieved neutrophil engraftment and the median time was 14 days (range, 12-32). Platelet counts ≥ 50 × 109 /L were recorded in all patients except for one who died on day 48; the median time was 34 days (range, 29-98). No relapse, thrombosis, or bone marrow fibrosis was observed during a median follow-up of 34 months. Romiplostim may be safely administered in the early phase of CBT. Further phase 2 trial is warranted for its efficacy evaluation. Trial registration number: UMIN000033799, August 18, 2018.
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Affiliation(s)
- Naoki Kurita
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan.
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan.
| | - Hidekazu Nishikii
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yumiko Maruyama
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yasuhito Suehara
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Keiichiro Hattori
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tatsuhiro Sakamoto
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takayasu Kato
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yasuhisa Yokoyama
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Naoshi Obara
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Kazushi Maruo
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Hitomi Yamaguchi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Toshiro Iwamoto
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Hideto Minohara
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Ryota Matsuoka
- Department of Diagnostic Pathology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Koichi Hashimoto
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Mamiko Sakata-Yanagimoto
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shigeru Chiba
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
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Dzik WS, Healy B, Brunker P, Ruby K, Collins J, Paik HI, Berra L, Shelton K, North CM, Makar R. Platelet transfusion in critical care: A new method to analyze transfusion practice based on decision time intervals. Transfusion 2023; 63:1661-1676. [PMID: 37606376 DOI: 10.1111/trf.17508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/22/2023] [Accepted: 06/24/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND While prior studies of platelet transfusion in critical care have focused on transfusions given, proper analysis of clinical transfusion practice also requires consideration of the decision not to transfuse. STUDY DESIGN AND METHODS We introduce a new method to assess transfusion practice based on decision time intervals (DTIs). Each patient's intensive care (ICU) stay was segmented into a series of DTIs defined by a time interval following results of a complete blood count (CBC). We studied the presence of 17 clinical factors during each DTI whether transfusion was given or not. We used a generalized linear mixed model to assess the most influential clinical triggers for platelet transfusion. RESULTS Among 6125 ICU patients treated between October 2016 and October 2021, we analyzed 39,745 DTIs among patients (n = 2921) who had at least one DTI with thrombocytopenia (≤150,000/μL). We found no association between platelet count and two markers of bleeding: drop in hemoglobin and chest tube drainage. We found that the majority of DTIs were associated with no platelet transfusion regardless of the platelet count; that no specific platelet value triggered transfusion; but rather that multiple clinical factors in conjunction with the platelet count influenced the decision to transfuse. DISCUSSION DTI analysis represents a new method to assess transfusion practice that considers both transfusions given and not given, and that analyzes clinical circumstances present when decisions regarding transfusion are made. The method is easily adapted to blood components other than platelet transfusions and is easily extended to other ICU and other hospital settings.
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Affiliation(s)
- Walter Sunny Dzik
- Blood Transfusion Service, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Brian Healy
- Department of Biostatistics, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Patricia Brunker
- Blood Transfusion Service, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Kristen Ruby
- Blood Transfusion Service, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Julia Collins
- Blood Transfusion Service, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Hyun-Il Paik
- Research Information Science and Computing, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Lorenzo Berra
- Anesthesia and Critical Care, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Kenneth Shelton
- Anesthesia and Critical Care, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Crystal M North
- Department of Pulmonary and Critical Care Medicine and Medical Practice Evaluation Center, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
| | - Robert Makar
- Blood Transfusion Service, Massachusetts General Hospital, MGB Healthcare, Boston, Massachusetts, USA
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5
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Péju E, Fouqué G, Charpentier J, Vigneron C, Jozwiak M, Cariou A, Mira JP, Jamme M, Pène F. Clinical significance of thrombocytopenia in patients with septic shock: An observational retrospective study. J Crit Care 2023; 76:154293. [PMID: 36989886 DOI: 10.1016/j.jcrc.2023.154293] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Whether thrombocytopenia in critically ill patients accounts for a bystander of severity or drives specific complications is unclear. We addressed the effect of thrombocytopenia on septic shock, with emphasis on intensive care unit (ICU)-acquired bleeding, infections and thrombotic complications. MATERIALS AND METHODS A retrospective (2008-2019) single-center study of patients with septic shock. Thrombocytopenia was assessed over the first seven days and was defined as severe (nadir <50 G/L), mild (nadir 50-150 G/L) and relative (30% decrease with nadir >150 G/L). Outcomes were ICU mortality and ICU-acquired complications defined by severe bleeding, infections and thrombotic events during the ICU stay. RESULTS The study comprised 1024 patients. Severe, mild and relative thrombocytopenia occurred in 33%, 40% and 9% of patients. The in-ICU mortality rate was 27%, independently associated with severe thrombocytopenia. ICU-acquired infections, hemorrhagic and thrombotic complications occurred in 27.5%, 13.3% and 11.6% of patients, respectively. Patients with severe, mild or relative thrombocytopenia exhibited higher incidences of bleeding events (20.3%, 15.3% and 14.4% vs. 3.6% in non-thrombocytopenic, p < 0.001), infections (35.2%, 21.9% and 33.3% vs. 23.1% in non-thrombocytopenic, p < 0.001) and thrombotic events (14.6%, 10.8% and 17.8% vs. 7.8% in non-thrombocytopenic, p = 0.03). Only severe thrombocytopenia remained independently associated with increased risk of bleeding. CONCLUSIONS Severe thrombocytopenia was independently associated with ICU mortality and increased risk of bleeding, but not with infectious and thrombotic events.
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Affiliation(s)
- Edwige Péju
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France
| | - Gaëlle Fouqué
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Julien Charpentier
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Clara Vigneron
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France
| | - Mathieu Jozwiak
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France
| | - Alain Cariou
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France
| | - Jean-Paul Mira
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France
| | - Matthieu Jamme
- Service de médecine intensive-réanimation, Hôpital Privé de l'Ouest Parisien, Ramsay Générale de Santé, 14 Rue Castiglione del Lago, 78190 Trappes, France; Centre de Recherche en Epidémiologie et Santé des Populations, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), INSERM U-1018, Université de Versailles Saint-Quentin, 16, avenue Paul Vaillant Couturier, 94807 Villejuif, France
| | - Frédéric Pène
- Service de médecine intensive-réanimation, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris Centre, 27 rue du faubourg Saint Jacques, 75014 Paris, France; Université Paris Cité, Paris, France; Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Cité, 22 rue Méchain, 75014 Paris, France.
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6
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van Baarle FLF, van de Weerdt EK, van der Velden WJFM, Ruiterkamp RA, Tuinman PR, Ypma PF, van den Bergh WM, Demandt AMP, Kerver ED, Jansen AJG, Westerweel PE, Arbous SM, Determann RM, van Mook WNKA, Koeman M, Mäkelburg ABU, van Lienden KP, Binnekade JM, Biemond BJ, Vlaar APJ. Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia. N Engl J Med 2023; 388:1956-1965. [PMID: 37224197 DOI: 10.1056/nejmoa2214322] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Transfusion guidelines regarding platelet-count thresholds before the placement of a central venous catheter (CVC) offer conflicting recommendations because of a lack of good-quality evidence. The routine use of ultrasound guidance has decreased CVC-related bleeding complications. METHODS In a multicenter, randomized, controlled, noninferiority trial, we randomly assigned patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimeter) who were being treated on the hematology ward or in the intensive care unit to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement. The primary outcome was catheter-related bleeding of grade 2 to 4; a key secondary outcome was grade 3 or 4 bleeding. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk. RESULTS We included 373 episodes of CVC placement involving 338 patients in the per-protocol primary analysis. Catheter-related bleeding of grade 2 to 4 occurred in 9 of 188 patients (4.8%) in the transfusion group and in 22 of 185 patients (11.9%) in the no-transfusion group (relative risk, 2.45; 90% confidence interval [CI], 1.27 to 4.70). Catheter-related bleeding of grade 3 or 4 occurred in 4 of 188 patients (2.1%) in the transfusion group and in 9 of 185 patients (4.9%) in the no-transfusion group (relative risk, 2.43; 95% CI, 0.75 to 7.93). A total of 15 adverse events were observed; of these events, 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as serious. The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement. CONCLUSIONS The withholding of prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion. (Funded by ZonMw; PACER Dutch Trial Register number, NL5534.).
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Affiliation(s)
- Floor L F van Baarle
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Emma K van de Weerdt
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Walter J F M van der Velden
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Roelof A Ruiterkamp
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Pieter R Tuinman
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Paula F Ypma
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Walter M van den Bergh
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Astrid M P Demandt
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Emile D Kerver
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - A J Gerard Jansen
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Peter E Westerweel
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Sesmu M Arbous
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Rogier M Determann
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Walther N K A van Mook
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Mirelle Koeman
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Anja B U Mäkelburg
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Krijn P van Lienden
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Jan M Binnekade
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Bart J Biemond
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
| | - Alexander P J Vlaar
- From the Departments of Intensive Care Medicine (F.L.F.B., E.K.W., J.M.B., A.P.J.V.) and Hematology (B.J.B.) and the Laboratory of Experimental Intensive Care and Anesthesiology (F.L.F.B., E.K.W., A.P.J.V.), Amsterdam University Medical Centers location University of Amsterdam, the Department of Intensive Care Medicine, Amsterdam University Medical Centers location Vrije Universiteit Amsterdam (P.R.T.), and the Departments of Oncology (E.D.K.) and Intensive Care Medicine (R.M.D.), OLVG, Amsterdam, the Department of Hematology, Radboud University Medical Center, Nijmegen (W.J.F.M.V., R.A.R.), the Departments of Hematology (P.F.Y.) and Intensive Care Medicine (M.K.), Haga Ziekenhuis, the Hague, the Departments of Critical Care (W.M.B.) and Hematology (A.B.U.M.), University Medical Center Groningen, University of Groningen, Groningen, the Departments of Hematology (A.M.P.D.) and Intensive Care Medicine (W.N.K.A.M.), Maastricht University Medical Center, Maastricht, the Department of Hematology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam (A.J.G.J.), the Department of Internal Medicine, Albert Schweitzer Ziekenhuis, Dordrecht (P.E.W.), the Department of Intensive Care Medicine, Leiden University Medical Center, Leiden (S.M.A.), and the Department of Interventional Radiology, St. Antonius Ziekenhuis, Nieuwegein (K.P.L.) - all in the Netherlands
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Shenker J, Abuelhija H, Karam O, Nellis M. Transfusion Strategies in the 21st Century: A Case-Based Narrative Report. Crit Care Clin 2023; 39:287-298. [PMID: 36898774 DOI: 10.1016/j.ccc.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The transfusion of all blood components (red blood cells, plasma, and platelets) has been associated with increased morbidity and mortality in children. It is essential that pediatric providers weigh the risks and benefits before transfusing a critically ill child. A growing body of evidence has demonstrated the safety of restrictive transfusion practices in critically ill children.
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Affiliation(s)
- Jennifer Shenker
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th Street, M508, New York, NY 10065, USA
| | - Hiba Abuelhija
- Pediatric Critical Care, Hadassah University Medical Center, Hadassah Ein Kerem, POB 12000, Jerusalem 911200, Israel
| | - Oliver Karam
- Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Marianne Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, 525 East 68th Street, M512, New York, NY 10065, USA.
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8
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Gnanaraj J, Basavarajegowda A, Kayal S, Sahoo D, Toora E, Dubashi B, Ganesan P. Optimising platelet usage during the induction therapy of acute myeloid leukaemia: Impact of physician education. Transfus Med 2023. [PMID: 36942594 DOI: 10.1111/tme.12967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 02/07/2023] [Accepted: 03/08/2023] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Platelet products are scarce and expensive resources to be used judiciously. However, inappropriate usage is common. Lack of physician awareness is an important issue. We implemented a physician education program (PEP) along with repeated WhatsApp reminders at our centre. We audited the platelet usage practise before and after the intervention. METHODS Charts of patients with acute myeloid leukaemia (AML) treated between January 2020 and August 2020 was reviewed, and the mean platelet usage per patient per day was calculated. Physician education was implemented between September 2020 and December 2020 (2 PowerPoint lectures of 20 min each and weekly WhatsApp messages containing the guidelines). Data of patients treated between Jan 2021 and August 2021 was prospectively audited to understand platelet usage and the indications for transfusions. The British Committee for the Standards in Haematology (BCSH) platelet transfusion guidelines were used as the adjudication tool to evaluate compliance. The mean platelet usage per day per kg body weight of a patient before and after the PEP was compared using the t-test. RESULTS Group A (before physician education) consisted of 22 patients, and group B (after physician education) consisted of 23 patients. The mean number of platelet transfusions for each patient in a day per kg body weight was 125.7 × 108 in group A whereas, after the PEP, it had reduced to 73.9 × 108 amounting to an absolute reduction of 51 × 108 (58.8%) from the baseline with a statistical significance of P = 0.001. After implementing the PEP, the mean number of random donor platelets used reduced by 10.25 units (34% reduction), and the mean single donor platelets used reduced by 0.83 units (19% reduction). The 190 requests for platelet transfusion received during this period were classified as appropriate (157/190), which constituted 82.63% of the requests, or inappropriate (33/190), which accounted for 17.36%. CONCLUSIONS A short-duration education programme supplemented with weekly WhatsApp messages and an active feedback mechanism on the rationale of platelet transfusion by the treating physician and transfusion specialist could significantly reduce platelet consumption during the therapy of acute myeloid leukaemia patients. This is a measure that can be considered by all high-volume haematology centres, which can improve patient safety and reduce costs.
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Affiliation(s)
- John Gnanaraj
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Abhishekh Basavarajegowda
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Dibyajyothi Sahoo
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Esha Toora
- Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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9
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Gao A, Zhang L, Zhong D. Chemotherapy-induced thrombocytopenia: literature review. Discov Oncol 2023; 14:10. [PMID: 36695938 PMCID: PMC9877263 DOI: 10.1007/s12672-023-00616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common condition that frequently results in reduced chemotherapy dosages, postponed treatment, bleeding, and unfavorable oncological outcomes. At present, there is no clear suggestions for preventing or treating CIT. Thrombopoietin (TPO) replacement therapy has been invented and used to treat CIT to promote the production of megakaryocytes and stimulate the formation of platelets. However, this treatment is limited to the risk of immunogenicity and cancer progression. Therefore, an unmet need exists for exploring alternatives to TPO to address the clinical issue of CIT. Application of appropriate therapeutic drugs may be due to understanding the potential mechanisms of CIT. Studies have shown that chemotherapy significantly affects various cells in bone marrow (BM) microenvironment, reduces their ability to support normal hematopoiesis, and may lead to BM damage, including CIT in cancer patients. This review focuses on the epidemiology and treatment of cancer patients with CIT. We also introduce some recent progress to understand the cellular and molecular mechanisms of chemotherapy inhibiting normal hematopoiesis and causing thrombocytopenia.
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Affiliation(s)
- Ai Gao
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China.
| | - Linlin Zhang
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China
| | - Diansheng Zhong
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China
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10
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Liker M, Bašić Kinda S, Duraković N, Bojanić I, Aurer I, Golubić Ćepulić B. The appropriateness of platelet transfusions in hematological patients and the potential for improvement. Transfus Clin Biol 2022; 30:212-218. [PMID: 36493919 DOI: 10.1016/j.tracli.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hematology patients are intensive platelet users. In clinical practice, a substantial proportion of platelet (PLT) transfusions are routinely administered outside the guidelines despite compelling evidence for recommendations. Those unnecessary PLT transfusions are an unjustified extra burden on a scarce healthcare resource and may also be detrimental to the patients. This study aims to evaluate indications and assess the appropriateness of PLT transfusion, as well as to identify common discrepancies and propose modalities for better compliance with guidelines. MATERIAL AND METHODS The audit of all PLT orders for adult hematological inpatients was conducted over 2 months. The assessment was performed using guidelines for PLT transfusion. Patient demographic, clinical, and transfusion data were collected from hospital electronic medical records. RESULTS Based on 286 PLT orders, 344 PCs were transfused to 67 patients: 235 (82.2%) prophylactical due to low PLT count, 34 (11.9%) preprocedural and 17 (5.9%) therapeutic. Overall, 105 (36.77%) PLT transfusions were inappropriate: 78 (33.2%) of all prophylactic PLT transfusions due to low PLT count, 17 (50%) off all preprocedural and 10 (58.8%) of all therapeutical transfusion. The major reason for PLT transfusion inappropriateness was transfusion above the recommended threshold. Double units of PCs were transfused in 36.7% of all PLT transfusions and 32.4% of them were considered inappropriate. CONCLUSION Our audit of PLT transfusion practice found a large proportion of inappropriate PLT transfusions. Based on the most common deviations from the guidelines a variety of targeted measures for improvement are proposed.
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Affiliation(s)
- Milica Liker
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Sandra Bašić Kinda
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia
| | - Nadira Duraković
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia
| | - Ines Bojanić
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia; University of Applied Health Sciences, Zagreb, Croatia
| | - Igor Aurer
- Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia
| | - Branka Golubić Ćepulić
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia; Division of Hematology, Department of Internal Medicine, Zagreb, University Hospital Centre Zagreb, Croatia; School of Medicine, University of Zagreb, Croatia; University of Applied Health Sciences, Zagreb, Croatia
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11
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O'Brien K, Bakhtary S, Benson K, Stephens L, Lu W. A National Survey of Outpatient Platelet Transfusion Practice. Am J Clin Pathol 2022; 158:687-691. [PMID: 36017577 DOI: 10.1093/ajcp/aqac102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/20/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Platelets are a limited resource frequently subject to inventory shortages. It benefits all to transfuse judiciously, according to evidence-based guidelines. Several organizations have published recommendations for platelet transfusions, but none specifically focused on outpatients. The Clinical Hemotherapy subsection of the Association for the Advancement of Blood & Biotherapies (AABB) Transfusion Medicine Subsection Coordinating Committee conducted a survey targeting outpatient transfusions to understand current practice in the United States. METHODS To determine use of platelets in the outpatient setting, a survey was developed, piloted, validated, and distributed by email to 735 AABB members. Frequencies were calculated and free-text comments categorized. RESULTS A total of 317 responses were received (43% response rate) from 44 states. Half the respondents' institutions have formal outpatient platelet guidelines. Slightly more than half the respondents (51%) with guidelines used a threshold of less than 10,000/µL when transfusing stable, afebrile outpatients, with 29% using less than 20,000/µL. Fewer than half (45%) monitored outpatient platelet use by prospective and retrospective audits, with the next-largest group (25%) using retrospective audits only. CONCLUSIONS Approximately half the respondents had outpatient guidelines, and half used a threshold of less than 10,000/µL when transfusing platelets to stable outpatients. Greater adoption of this threshold and monitoring may improve the nation's platelet inventory.
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Affiliation(s)
- Kerry O'Brien
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kaaron Benson
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Laura Stephens
- Department of Pathology, University of Arizona, Tucson, AZ, USA
| | - Wen Lu
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
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12
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Chen Y, Buhlinger K, Perissinotti AJ, Schepers AJ, Benitez L, Auten J, Chen SL, Bixby DL, Burke PW, Pettit KM, Marini BL. Solving coagulation conundrums: comparing prophylaxis strategies in adult patients receiving PEG-asparaginase. Leuk Lymphoma 2022; 63:2663-2670. [DOI: 10.1080/10428194.2022.2087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Kaitlyn Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anthony J. Perissinotti
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Allison J. Schepers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Lydia Benitez
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Jessica Auten
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Dale L. Bixby
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick W. Burke
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M. Pettit
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Bernard L. Marini
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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13
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Best practice & research: Clinical hematology review on thrombosis and bleeding in hematological malignancy. Best Pract Res Clin Haematol 2022; 35:101353. [DOI: 10.1016/j.beha.2022.101353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 01/19/2023]
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14
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Marini I, Uzun G, Jamal K, Bakchoul T. Treatment of drug-induced immune thrombocytopenias. Haematologica 2022; 107:1264-1277. [PMID: 35642486 PMCID: PMC9152960 DOI: 10.3324/haematol.2021.279484] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Several therapeutic agents can cause thrombocytopenia by either immune-mediated or non-immune-mediated mechanisms. Non-immune-mediated thrombocytopenia is due to direct toxicity of drug molecules to platelets or megakaryocytes. Immune-mediated thrombocytopenia, on the other hand, involves the formation of antibodies that react to platelet-specific glycoprotein complexes, as in classic drug-induced immune thrombocytopenia (DITP), or to platelet factor 4, as in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT). Clinical signs include a rapid drop in platelet count, bleeding or thrombosis. Since the patient's condition can deteriorate rapidly, prompt diagnosis and management are critical. However, the necessary diagnostic tests are only available in specialized laboratories. Therefore, the most demanding step in treatment is to identify the agent responsible for thrombocytopenia, which often proves difficult because many patients are taking multiple medications and have comorbidities that can themselves also cause thrombocytopenia. While DITP is commonly associated with an increased risk of bleeding, HIT and VITT have a high mortality rate due to the high incidence of thromboembolic complications. A structured approach to drug-associated thrombocytopenia/thrombosis can lead to successful treatment and a lower mortality rate. In addition to describing the treatment of DITP, HIT, VITT, and vaccine-associated immune thrombocytopenia, this review also provides the pathophysiological and clinical information necessary for correct patient management.
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Affiliation(s)
- Irene Marini
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Gunalp Uzun
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Kinan Jamal
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen.
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15
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Kuter DJ. Treatment of chemotherapy-induced thrombocytopenia in patients with non-hematologic malignancies. Haematologica 2022; 107:1243-1263. [PMID: 35642485 PMCID: PMC9152964 DOI: 10.3324/haematol.2021.279512] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of the treatment of non-hematologic malignancies. Many patient-related variables (e.g., age, tumor type, number of prior chemotherapy cycles, amount of bone marrow tumor involvement) determine the extent of CIT. CIT is related to the type and dose of chemotherapy, with regimens containing gemcitabine, platinum, or temozolomide producing it most commonly. Bleeding and the need for platelet transfusions in CIT are rather uncommon except in patients with platelet counts below 25x109/L in whom bleeding rates increase significantly and platelet transfusions are the only treatment. Nonetheless, platelet counts below 70x109/L present a challenge. In patients with such counts, it is important to exclude other causes of thrombocytopenia (medications, infection, thrombotic microangiopathy, post-transfusion purpura, coagulopathy and immune thrombocytopenia). If these are not present, the common approach is to reduce chemotherapy dose intensity or switch to other agents. Unfortunately decreasing relative dose intensity is associated with reduced tumor response and remission rates. Thrombopoietic growth factors (recombinant human thrombopoietin, pegylated human megakaryocyte growth and development factor, romiplostim, eltrombopag, avatrombopag and hetrombopag) improve pretreatment and nadir platelet counts, reduce the need for platelet transfusions, and enable chemotherapy dose intensity to be maintained. National Comprehensive Cancer Network guidelines permit their use but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival. Their potential appropriate use also depends on consensus by the oncology community as to what constitutes an appropriate pretreatment platelet count as well as identification of patient-related and treatment variables that might predict bleeding.
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Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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16
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There and Back Again: The Once and Current Developments in Donor-Derived Platelet Products for Products for Hemostatic Therapy. Blood 2022; 139:3688-3698. [PMID: 35482959 DOI: 10.1182/blood.2021014889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/20/2022] [Indexed: 01/19/2023] Open
Abstract
Over 100 years ago, Duke transfused whole blood to a thrombocytopenic patient to raise the platelet count and prevent bleeding. Since then, platelet transfusions have undergone numerous modifications from whole blood-derived platelet-rich plasma to apheresis-derived platelet concentrates. Similarly, the storage time and temperature have changed. The mandate to store platelets for a maximum of 5-7 days at room temperature has been challenged by recent clinical trial data, ongoing difficulties with transfusion-transmitted infections, and recurring periods of shortages, further exacerbated by the COVID-19 pandemic. Alternative platelet storage approaches are as old as the first platelet transfusions. Cold-stored platelets may offer increased storage times (days) and improved hemostatic potential at the expense of reduced circulation time. Frozen (cryopreserved) platelets extend the storage time to years but require storage at -80 °C and thawing before transfusion. Lyophilized platelets can be powder-stored for years at room temperature and reconstituted within minutes in sterile water but are probably the least explored alternative platelet product to date. Finally, whole blood offers the hemostatic spectrum of all blood components but has challenges, such as ABO incompatibility. While we know more than ever before about the in vitro properties of these products, clinical trial data on these products are accumulating. The purpose of this review is to summarize the findings of recent preclinical and clinical studies on alternative, donor-derived platelet products.
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17
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Schiffer CA. Commentary on the prescient observations made by Emil J Freireich in Effectiveness of platelet transfusion in leukemia and aplastic anemia (Transfusion 1966; 6: 50-54). Transfusion 2022; 62:267-272. [PMID: 35146768 DOI: 10.1111/trf.16784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Charles A Schiffer
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan, USA
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18
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Lieberman L, Karam O, Stanworth SJ, Goobie SM, Crighton G, Goel R, Lacroix J, Nellis ME, Parker RI, Steffen K, Stricker P, Valentine SL, Steiner ME. Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e37-e49. [PMID: 34989704 PMCID: PMC8769367 DOI: 10.1097/pcc.0000000000002857] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements. CONCLUSIONS In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network Hospitals. Department of Laboratory Medicine & Pathobiology; University of Toronto, Toronto, Canada
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Simon J. Stanworth
- NHS Blood and Transplant; Oxford University Hospitals NHS Foundation Trust; Radcliffe Department of Medicine and Oxford BRC Haematology Theme, University of Oxford, UK
| | - Susan M. Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Gemma Crighton
- Department of Haematology, Royal Children’s Hospital, Melbourne, Australia
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD and Simmons Cancer Institute, Division of Hematology Oncology at SIU School of Medicine, Springfield, IL, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, QC, Canada
| | - Marianne E. Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital – Weill Cornell Medicine, New York, NY, USA
| | - Robert I. Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Katherine Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Paul Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Stacey L. Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
| | - Marie E. Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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19
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Bumbea H, Vladareanu AM, Dumitru I, Popov VM, Ciufu C, Nicolescu A, Onisai M, Marinescu C, Cisleanu D, Voican I, Sarghi S. Platelet Defects in Acute Myeloid Leukemia-Potential for Hemorrhagic Events. J Clin Med 2021; 11:jcm11010118. [PMID: 35011859 PMCID: PMC8745388 DOI: 10.3390/jcm11010118] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/04/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background and objectives: In acute myeloid leukemia (AML), extensive bleeding is one of the most frequent causes of death. Impaired activation and aggregation processes were identified in previous studies on platelet behaviour associated with this disease. This study’s aim was to examine platelet function in correlation with other haemorrhage risk factors (fever, sepsis, recent bleeding, uraemia, leucocytosis, haematocrit value, treatment). Design and methods: The analysis of platelet surface proteins (Glycoprotein Ib-IX (CD42b, CD42a), Glycoprotein IIb-IIIa (CD41, CD61), p-selectin (CD62P), granulophysin (CD63)) was conducted by flowcytometry from samples of whole blood in patients with acute myeloid leukaemia in different stages of diagnosis and therapy (n = 22) in comparison with healthy human controls (n = 10). Results and interpretations: Our results show a significant decrease in fluorescence level associated with platelet activation markers (CD63 (14.11% vs. 40.78 % p < 0.05); CD62P (15.26% vs. 28.23% p < 0.05)); adhesion markers (CD42b (69.08% vs. 84.41% p < 0.05)) and aggregation markers (CD61 (83.79% vs. 98.62% p < 0.001)) in patients compared to controls. The levels of CD41 (80.62% vs. 86.31%, p = 0.290) and CD42a (77.98% vs. 94.15%, p = 0.99) demonstrate no significant differences in the two groups. Conclusion: The AML patients present changes in adhesion receptors and activation markers, suggesting a functional defect or denatured intracellular signalling in platelets. The exposed data indicate that flow cytometry can effectively identify multiple functional platelet impairments in AML pathogenesis.
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Affiliation(s)
- Horia Bumbea
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ana Maria Vladareanu
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ion Dumitru
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
| | - Viola Maria Popov
- Department of Hematology, Colentina Clinical Hospital, 020125 Bucharest, Romania
- Correspondence:
| | - Cristina Ciufu
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Anca Nicolescu
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
| | - Minodora Onisai
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Cristina Marinescu
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Diana Cisleanu
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Irina Voican
- Department of Hematology, Emergency University Hospital, 050098 Bucharest, Romania; (H.B.); (A.M.V.); (I.D.); (C.C.); (A.N.); (M.O.); (C.M.); (D.C.); (I.V.)
| | - Sinziana Sarghi
- (VP) Centre, Hospitalier René Dubos, 6 Avenue de l’île de France, 95300 Pontoise, France;
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Koschade SE, Stratmann JA, Miesbach W, Steffen B, Serve H, Finkelmeier F, Brandts CH, Ballo O. Intracranial hemorrhage in newly diagnosed non-promyelocytic acute myeloid leukemia patients admitted for intensive induction chemotherapy. Eur J Haematol 2021; 108:125-132. [PMID: 34714547 DOI: 10.1111/ejh.13718] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/19/2021] [Accepted: 10/25/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES AND METHODS Intracranial hemorrhage (ICH) in acute myeloid leukemia (AML) patients is a major concern due to the increased risk of mortality. Few studies have examined ICH specifically in newly diagnosed AML patients receiving intensive induction chemotherapy (IC) and prophylactic platelet transfusions during thrombocytopenia <10/nL. This retrospective cohort study included 423 newly diagnosed AML patients without acute promyelocytic leukemia who underwent IC between 2007 and 2019. We assessed risk factors, clinical features, and outcomes of ICH. RESULTS 17 of 423 patients (4%) suffered ICH during hospital stay, and 4 patients (24%) died directly because of ICH despite routine prophylactic platelet transfusions. Patients with ICH had a negatively impacted overall survival (median OS, 20.1 vs. 104.8 months) and were more likely not to continue with curative treatment. Main risk factors were female gender, severe thrombocytopenia, and decreased fibrinogen. Patients with subsequent ICH also had laboratory signs of liver dysfunction. CONCLUSIONS Intracranial hemorrhage remains a potentially deadly complication with notable incidence despite prophylactic platelet substitution, suggesting that additional prophylactic interventions may be required to further reduce the frequency of ICH in high-risk patients. Unrecognized genetic factors may simultaneously predispose to AML and platelet dysfunction with ICH.
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Affiliation(s)
- Sebastian E Koschade
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Jan A Stratmann
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Haemostaseology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- University Cancer Center Frankfurt (UCT), University Hospital, Goethe University, Frankfurt am Main, Germany.,Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Christian H Brandts
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital, Goethe University, Frankfurt am Main, Germany
| | - Olivier Ballo
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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Anthon CT, Sivapalan P, Granholm A, Pène F, Puxty K, Perner A, Møller MH, Russell L. Prophylactic platelet transfusions in hospitalised patients with thrombocytopenia-Protocol for a systematic review with meta-analysis. Acta Anaesthesiol Scand 2021; 65:988-994. [PMID: 33840095 DOI: 10.1111/aas.13826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 02/27/2021] [Accepted: 03/27/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Prophylactic platelet transfusions are frequently used to prevent bleeding in hospitalised patients with thrombocytopenia. Recommendations regarding the use of prophylactic platelet transfusions in non-haematological patients are based on extrapolations, observational studies, and expert opinions, and transfusion with platelets has been associated with adverse effects. We aim to assess the overall benefits and harms of prophylactic platelet transfusions in hospitalised patients with thrombocytopenia. METHODS/DESIGN We will conduct a systematic review with meta-analyses and trial sequential analyses in compliance with the recommendations by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We will prepare the manuscript in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We will include randomised clinical trials assessing prophylactic platelet transfusion versus no prophylaxis or placebo in hospitalised patients with thrombocytopenia. The primary outcome is mortality at longest follow-up. Secondary outcomes include episodes of clinically important bleeding, nosocomial infections, transfusion-related adverse events, thromboembolic events, length of hospital stay, quality of life, and days alive without the use of life support. We will conduct prespecified subgroup analyses and sensitivity analyses and assess the risk of random errors by trial sequential analyses. DISCUSSION The proposed systematic review will provide an overview of the certainty of evidence for the benefits and harms of prophylactic platelet transfusion in hospitalised patients with thrombocytopenia.
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Affiliation(s)
- Carl T. Anthon
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Praleene Sivapalan
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Frédéric Pène
- Médecine Intensive & Réanimation Faculté de Médecine Paris Descartes Hôpital CochinAP‐HP Paris France
| | | | - Anders Perner
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Lene Russell
- Department of Intensive Care RigshospitaletUniversity of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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22
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Platelet and Red Blood Cell Transfusions and Risk of Acute Graft-versus-Host Disease after Myeloablative Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:866.e1-866.e9. [PMID: 34252580 DOI: 10.1016/j.jtct.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/28/2021] [Accepted: 07/04/2021] [Indexed: 12/22/2022]
Abstract
Transfusion therapy is a critical part of supportive care early after allogeneic hematopoietic cell transplantation (allo-HCT). Platelet and RBC transfusions elicit immunomodulatory effects in the recipient, but if this impacts the risk of acute graft-versus-host disease (aGVHD) has only been scarcely investigated. We investigated if platelet and RBC transfusions were associated with the development of aGVHD following myeloablative allo-HCT in a cohort of 664 patients who underwent transplantation between 2000 and 2019. Data were further analyzed for the impact of blood donor age and sex and blood product storage time. Exploratory analyses were conducted to assess correlations between transfusion burden and plasma biomarkers of inflammation and endothelial activation and damage. Between day 0 and day +13, each patient received a median of 7 (IQR, 5 to 10) platelet transfusions and 3 (IQR, 2 to 6) RBC transfusions (Spearman's ρ = 0.49). The cumulative sums of platelet and RBC transfusions, respectively, received from day 0 to day +13 were associated with subsequent grade II-IV aGVHD in multivariable landmark Cox models (platelets: adjusted hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.06 to 1.51; RBCs: adjusted HR, 1.41; 95% CI, 1.09 to 1.82; both per 5 units; 184 events). For both platelet and RBC transfusions, we did not find support for a difference in the risk of aGVHD according to age or sex of the blood donor. Transfusion of RBCs with a storage time longer than the median of 8 days was inversely associated with aGVHD (HR per 5 units, 0.54; 95% CI, 0.30 to 0.96); however, when using an RBC storage time of ≥14 days as a cutoff, there was no longer evidence for an association with aGVHD (HR, 1.03 per 5 units; 95% CI, 0.53 to 2.00). For platelets, there was no clear association between storage time and the risk of aGVHD. The transfusion burdens of platelets and RBCs were positively correlated with plasma levels of TNF-α, IL-6, and soluble thrombomodulin at day +14. In conclusion, platelet and RBC transfusions in the first 2 weeks after myeloablative allo-HCT were associated with subsequent development of grade II-IV aGVHD. We did not find evidence of an impact of blood donor age or sex or blood product storage time on the risk of aGVHD. Our findings support restrictive transfusion strategies in allo-HCT recipients.
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Murphy C, Mou E, Pang E, Shieh L, Hom J, Shah N. A randomized study of a best practice alert for platelet transfusions. Vox Sang 2021; 117:87-93. [PMID: 34081800 DOI: 10.1111/vox.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/20/2021] [Accepted: 05/01/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Inappropriate platelet transfusions represent an opportunity for improvements in patient care. Use of a best practice alert (BPA) as clinical decision support (CDS) for red cell transfusions has successfully reduced unnecessary red blood cell (RBC) transfusions in prior studies. We studied the impact of a platelet transfusion BPA with visibility randomized by patient chart. MATERIALS AND METHODS A BPA was built to introduce CDS at the time of platelet ordering in the electronic health record. Alert visibility was randomized at the patient encounter level. BPA eligible platelet transfusions for patients with both visible and non-visible alerts were recorded along with reasons given for override of the BPA. Focused interviews were performed with providers who interacted with the BPA to assess its impact on their decision making. RESULTS Over a 9-month study period, 446 patient charts were randomized. The visible alert group used 25.3% fewer BPA eligible platelets. Mean monthly usage of platelets eligible for BPA display was 65.7 for the control group and 49.1 for the visible alert group (p = 0.07). BPA-eligible platelets used per inpatient day at risk per month were not significantly different between groups (2.4 vs. 2.1, p = 0.53). CONCLUSION It is feasible to study CDS via chart-based randomization. A platelet BPA reduced total platelets used over the study period and may have resulted in $151,069 in yearly savings, although there were no differences when adjusted for inpatient days at risk. During interviews, providers offered additional workflow insights allowing further improvement of CDS for platelet transfusions.
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Affiliation(s)
- Colin Murphy
- Division of Transfusion Medicine, Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Mou
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Emily Pang
- Stanford University School of Medicine, Stanford, California, USA
| | - Lisa Shieh
- Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Neil Shah
- Division of Transfusion Medicine, Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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24
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Hadid T, Kafri Z, Al-Katib A. Coagulation and anticoagulation in COVID-19. Blood Rev 2021; 47:100761. [PMID: 33067035 PMCID: PMC7543932 DOI: 10.1016/j.blre.2020.100761] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/23/2020] [Accepted: 10/02/2020] [Indexed: 02/07/2023]
Abstract
COVID-19 has become a pandemic in the United States and worldwide. COVID-19-induced coagulopathy (CIC) is commonly encountered at presentation manifested by considerable elevation of D-dimer and fibrin split products but with modest or no change in activated partial thromboplastin time and prothrombin time. CIC is a complex process that is distinctly different from conventional sepsis-induced coagulopathy. The cytokine storm induced by COVID-19 infection appears to be more severe in COVID-19, resulting in development of extensive micro- and macrovascular thrombosis and organ failure. Unlike conventional sepsis, anticoagulation plays a key role in the treatment of COVID-19, however without practice guidelines tailored to these patients. We propose a scoring system for COVID-19-coagulopathy (CIC Scoring) and stratification of patients for the purpose of anticoagulation therapy based on risk categories. The proposed scoring system and therapeutic guidelines are likely to undergo revisions in the future as new data become available in this evolving field.
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Affiliation(s)
- Tarik Hadid
- Department of Internal Medicine, Wayne State University, School of Medicine, Detroit, MI, USA; Ascension Michigan, Detroit, MI, USA.
| | - Zyad Kafri
- Department of Internal Medicine, Wayne State University, School of Medicine, Detroit, MI, USA; Ascension Michigan, Detroit, MI, USA
| | - Ayad Al-Katib
- Department of Internal Medicine, Wayne State University, School of Medicine, Detroit, MI, USA
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25
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Lisman T, Hernandez‐Gea V, Magnusson M, Roberts L, Stanworth S, Thachil J, Tripodi A. The concept of rebalanced hemostasis in patients with liver disease: Communication from the ISTH SSC working group on hemostatic management of patients with liver disease. J Thromb Haemost 2021; 19:1116-1122. [PMID: 33792172 PMCID: PMC8252070 DOI: 10.1111/jth.15239] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022]
Abstract
Patients with liver diseases acquire complex alterations in their hemostatic system that may lead to abnormalities in routine diagnostic test of hemostasis. Thrombocytopenia, prolongations in the prothrombin time and activated partial thromboplastin time, and decreased plasma fibrinogen are common in patients with advanced liver disease. Historically, liver diseases therefore have been classified as an acquired bleeding disorder. Laboratory and clinical observations have demonstrated that although routine diagnostic tests of hemostasis suggest a hypocoagulable state, patients with liver disease also tend to develop thrombotic events. Overall, patients have commensurate changes in both pro- and antihemostatic pathways. This new hemostatic balance, however, appears much more fragile than the hemostatic balance in individuals with normal liver function, and patients with liver disease can readily experience both hemostasis-related bleeding and thrombotic events. These insights into the hemostatic balance in patients with liver disease have led to revised recommendations for clinical management of hemostasis. In 2020, an SSC working group within the ISTH has been founded with the aim to disseminate new concepts on prevention and treatment of bleeding and thrombosis in patients with liver disease. The current document will outline the hemostatic changes in patients with liver disease, the limitations of routine diagnostic tests of hemostasis, and the concept of rebalanced hemostasis.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Virginia Hernandez‐Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital ClínicIDIBAPSUniversity of BarcelonaCentro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN‐Liver)BarcelonaSpain
| | - Maria Magnusson
- Clinical Chemistry and Blood Coagulation ResearchMMKDepartment of PediatricsCLINTECKarolinska InstitutetDepartment of HematologyKarolinska University HospitalStockholmSweden
| | - Lara Roberts
- King's Thrombosis CentreDepartment of Haematological MedicineKing's College HospitalLondonUK
| | - Simon Stanworth
- Transfusion MedicineNHS Blood and TransplantOxfordUK
- Department of HaematologyOxford University HospitalsNHS Foundation TrustOxfordUK
- Radcliffe Department of MedicineUniversity of Oxford and NIHR Oxford Biomedical Research Centre (Haematology)OxfordUK
| | - Jecko Thachil
- Department of HaematologyManchester Royal InfirmaryManchesterUK
| | - Armando Tripodi
- IRCCS Ca’ Granda Maggiore Hospital FoundationAngelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi VillaMilanoItaly
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26
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27
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Laroche V, Blais‐Normandin I. Clinical Uses of Blood Components. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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28
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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29
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Lien F, Wang HY, Lu JJ, Wen YH, Chiueh TS. Predicting 2-Day Mortality of Thrombocytopenic Patients Based on Clinical Laboratory Data Using Machine Learning. Med Care 2021; 59:245-250. [PMID: 33027237 PMCID: PMC7993911 DOI: 10.1097/mlr.0000000000001421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Clinical laboratories have traditionally used a single critical value for thrombocytopenic events. This system, however, could lead to inaccuracies and inefficiencies, causing alarm fatigue and compromised patient safety. OBJECTIVES This study shows how machine learning (ML) models can provide auxiliary information for more accurate identification of critical thrombocytopenic patients when compared with the traditional notification system. RESEARCH DESIGN A total of 50,505 patients' platelet count and other 26 additional laboratory datasets of each thrombocytopenic event were used to build prediction models. Conventional logistic regression and ML methods, including random forest (RF), artificial neural network, stochastic gradient descent (SGD), naive Bayes, support vector machine, and decision tree, were applied to build different models and evaluated. RESULTS Models using logistic regression [area under the curve (AUC)=0.842], RF (AUC=0.859), artificial neural network (AUC=0.867), or SGD (AUC=0.826) achieved the desired average AUC>0.80. The highest positive predictive value was obtained by the SGD model in the testing data (72.2%), whereas overall, the RF model showed higher sensitivity and total positive predictions in both the training and testing data and outperformed other models. The positive 2-day mortality predictive rate of RF methods is as high as 46.1%-significantly higher than using the traditional notification system at only 14.8% [χ2(1)=81.66, P<0.001]. CONCLUSIONS This study demonstrates a data-driven ML approach showing a significantly more accurate 2-day mortality prediction after a critical thrombocytopenic event, which can reinforce the accuracy of the traditional notification system.
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Affiliation(s)
- Frank Lien
- Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital
| | - Hsin-Yao Wang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital
- Department of Internal Medicine, Chang Gung University, TaoYuan, Taiwan
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital
| | - Ying-Hao Wen
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital
- Department of Internal Medicine, Chang Gung University, TaoYuan, Taiwan
| | - Tzong-Shi Chiueh
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital
- Department of Internal Medicine, Chang Gung University, TaoYuan, Taiwan
- New Taipei Municipal TuCheng Hospital, TuCheng, New Taipei
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30
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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31
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Aran AA, Karam O, Nellis ME. Bleeding in Critically Ill Children-Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation. Front Pediatr 2021; 9:611680. [PMID: 33585373 PMCID: PMC7873638 DOI: 10.3389/fped.2021.611680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.
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Affiliation(s)
- Adi Avniel Aran
- Pediatric Cardiac Critical Care Division, Hadassah University Medical Center, Jerusalem, Israel
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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32
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Triulzi DJ. How well do platelets prevent bleeding? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:518-522. [PMID: 33275687 PMCID: PMC7727555 DOI: 10.1182/hematology.2020000136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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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Affiliation(s)
- Darrell J Triulzi
- University of Pittsburgh, Vitalant Clinical Services, Pittsburgh, PA
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33
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Wang TF, Makar RS, Antic D, Levy JH, Douketis JD, Connors JM, Carrier M, Zwicker JI. Management of hemostatic complications in acute leukemia: Guidance from the SSC of the ISTH. J Thromb Haemost 2020; 18:3174-3183. [PMID: 33433069 PMCID: PMC7909744 DOI: 10.1111/jth.15074] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/29/2022]
Abstract
Patients with acute leukemia frequently develop thrombocytopenia and hemostatic complications caused by coagulopathy. Coagulopathy complicates the management of these patients and can lead to significant morbidity and mortality. This guidance document aims to review and provide guidance on the management of hemostatic complications in adult patients with acute leukemia, addressing four main issues, including platelet transfusion, disseminated intravascular coagulation, L-asparaginase-related hypofibrinogenemia, and the use of antifibrinolytic agents.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Robert S. Makar
- Blood Transfusion Service, Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey I. Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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34
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Roberts N, James SL, Delaney M, Fitzmaurice C. Blood transfusion trends by disease category in the United States, 2000 to 2014. Transfus Apher Sci 2020; 60:103012. [PMID: 33309539 DOI: 10.1016/j.transci.2020.103012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Better understanding of blood usage rates could identify trends in transfusion practices over time and inform more efficient management. METHODS Inpatient admissions from the Healthcare Cost and Utilization Project National Inpatient Sample and State Inpatient Databases were analyzed for packed red blood cell (PRBC), plasma, platelet, and whole blood (WB) transfusions. The transfusion rates per admission and per prevalent case were calculated. Prevalence estimates were from the Global Burden of Disease 2017 study (GBD). RESULTS From 2000 to 2014, blood usage rates for most causes peaked around 2010. Across all causes, PRBC were the most commonly transfused component, followed by plasma, platelets, and WB. However, the relative use of each type varied by cause. Nutritional deficiencies (1.75 blood product units across all components per admission; 95 % uncertainty interval (UI) 1.62-1.87), neoplasms (0.95; 0.87-1.04), and injuries (0.92; 0.86 - 0.98) had the greatest blood use per admission. Cardiovascular diseases (96.9 units per 1000 prevalent cases; 89.3-105.0) and neoplasms (92.7 units per 1000 prevalent cases; 84.3-101.5) had the greatest blood use per prevalent case. Across all admissions, over three million blood units were saved in 2014 compared to 2011 due to transfusing at a reduced rate. CONCLUSIONS Blood transfusion rates decreased from 2011 to 2014 in the United States. This decline occurred in most disease categories, which points towards broad strategies like patient blood management systems and disease specific improvements like changes in surgical techniques being effective.
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Affiliation(s)
- Nicholas Roberts
- Department of Health Metric Sciences, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States.
| | - Spencer L James
- Department of Health Metric Sciences, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States
| | - Meghan Delaney
- Division of Pathology & Laboratory Medicine, Children's National Medical Center, Washington, DC, United States; Departments of Pathology & Pediatrics, George Washington University Medical School, Washington DC, United States
| | - Christina Fitzmaurice
- Department of Health Metric Sciences, Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, United States
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Slichter SJ, Gernsheimer T, LeBlanc R, Townsend-McCall D, Jones MK, Cuaron L, Bolgiano D. Fecal blood loss: A quantitative method of evaluating hemostasis in patients with thrombocytopenia. Transfusion 2020; 61:393-403. [PMID: 33166412 DOI: 10.1111/trf.16167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 09/27/2020] [Accepted: 10/03/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The purpose of our studies was to determine if fecal blood loss can provide a quantitative measure of bleeding at platelet counts of 20 000/μL or less in patients with hypoproliferative thrombocytopenia and to document the effects of different prophylactic platelet transfusion triggers on fecal blood loss. METHODS AND MATERIALS Patients had an aliquot of their autologous red blood cells (RBCs) labeled with 51 Cr. Following reinjection of their radiolabeled RBCs, all feces and a daily blood sample were collected to determine fecal blood loss per day. Three different studies were performed in patients with thrombocytopenia: The first was in patients with thrombocytopenia with aplastic anemia who were not receiving platelet transfusions, and the other two trials involved thrombocytopenic patients with cancer who were receiving prophylactic platelet transfusions at platelet transfusion triggers of 5000/μL, 10 000/μL, or 20 000/μL. RESULTS In patients with thrombocytopenia not receiving platelet transfusions, fecal blood loss does not increase substantially until platelet counts are 5000/μL or less. When platelet transfusions are given prophylactically to patients with cancer with chemotherapy-induced thrombocytopenia at platelet counts of 5000/μL or less, fecal blood loss and red cell transfusion requirements are the same as those for patients transfused prophylactically at higher transfusion triggers of 10 000 platelets/μL or 20 000 platelets/μL. However, the total number of platelet transfusions needed increases significantly, and the duration of the patient's thrombocytopenia tends to be longer at the higher platelet transfusion thresholds. CONCLUSION A prophylactic platelet transfusion threshold of 5000/μL or greater is sufficient to maintain hemostasis in patients with thrombocytopenia.
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Affiliation(s)
- Sherrill J Slichter
- Research Institute, Bloodworks Northwest, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Terry Gernsheimer
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Renee LeBlanc
- Research Institute, Bloodworks Northwest, Seattle, Washington, USA
| | | | - Mary Kay Jones
- Research Institute, Bloodworks Northwest, Seattle, Washington, USA
| | - Linda Cuaron
- Research Institute, Bloodworks Northwest, Seattle, Washington, USA
| | - Doug Bolgiano
- Research Institute, Bloodworks Northwest, Seattle, Washington, USA
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Atari B, Ito T, Nagasato T, Ohnishi T, Hosokawa K, Yasuda T, Maruyama I, Kakihana Y. A modified microchip-based flow chamber system for evaluating thrombogenicity in patients with thrombocytopenia. Thromb J 2020; 18:31. [PMID: 33292286 PMCID: PMC7602342 DOI: 10.1186/s12959-020-00244-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In the intensive care unit (ICU), patients with thrombocytopenia are at high risk for bleeding and should be assessed for their thrombogenic potential. However, the analytical conditions of conventional hemostatic tests are unsuitable for the evaluation of low-platelet samples. Here we aimed to establish suitable analytical conditions with the Total Thrombus-formation Analysis System (T-TAS) for quantitative assessment of thrombogenic potential in patients with thrombocytopenia and to investigate how T-TAS values relate to bleeding symptoms and the effects of platelet transfusion. METHODS Modified chips with a different chamber depth were developed for the analysis of low-platelet samples in the T-TAS. We included 10 adult patients admitted to the ICU of Kagoshima University Hospital who required platelet transfusion. Patients were divided into major and minor bleeding groups according to their bleeding scale before platelet transfusion. The thrombogenic potential of these patients before and after platelet transfusion was assessed with hemostatic function tests, including rotational thromboelastometry, multiplate aggregometry, and the T-TAS. RESULTS Analysis of low-platelet samples revealed that, compared with the conventional chip (80-μm-deep chamber), the modified chip (50-μm-deep chamber) achieved higher sensitivity in detecting elevation of flow pressure caused by growth of an occlusive thrombus in the T-TAS analytical chamber. All patients in the minor bleeding group retained thrombogenic potential that occluded the modified chip (occlusion time 16.3 ± 3.3 min), whereas most patients in the major bleeding group were unable to occlude the modified chip during the 30-min measurement (P < 0.01). The recovery of thrombogenic potential after platelet transfusion was confirmed with the T-TAS and correlated with the function, rather than the count, of transfused platelets. Among all evaluated parameters in hemostatic function tests, only the T-TAS showed significant differences in occlusion time and area under the curve both between the minor and major bleeding groups and between pre- and post-platelet transfusion. CONCLUSIONS We developed a modified microchip-based flow chamber system that reflects the hemostatic function of patients with thrombocytopenia.
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Affiliation(s)
- Bengo Atari
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takashi Ito
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan.
| | - Tomoka Nagasato
- Research Institute, Fujimori Kogyo Co., Ltd., Yokohama, Japan
| | - Tomoko Ohnishi
- Research Institute, Fujimori Kogyo Co., Ltd., Yokohama, Japan
| | - Kazuya Hosokawa
- Research Institute, Fujimori Kogyo Co., Ltd., Yokohama, Japan
| | - Tomotsugu Yasuda
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Ikuro Maruyama
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8544, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Hill-Strathy M, Pinkerton PH, Thompson TA, Wendt A, Collins A, Cohen R, BComm WO, Cameron T, Lin Y, Lau W, Lieberman L, Callum J. Evaluating the appropriateness of platelet transfusions compared with evidence-based platelet guidelines: An audit of platelet transfusions at 57 hospitals. Transfusion 2020; 61:57-71. [PMID: 33078852 DOI: 10.1111/trf.16134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelet transfusions are used to prevent or control bleeding in patients with thrombocytopenia or platelet dysfunction. The pretransfusion platelet count threshold has been studied extensively in multiple patient settings yielding high-quality evidence that has been summarized in several comprehensive evidence-based platelet guidelines. STUDY DESIGN AND METHODS A prospective 12-week audit of consecutive platelet transfusions using validated and evidence-based adjudication criteria was conducted. Patient demographic, laboratory, and transfusion details were collected with an electronic audit tool. Each order was adjudicated either electronically or independently by two transfusion medicine physicians. The aim was to determine platelet transfusion appropriateness and common scenarios with deviations from guidelines. RESULTS Fifty-seven (38%) of 150 hospitals provided data on 1903 platelet orders, representing 90% of platelet usage in the region during the time period. Overall, 702 of 1693 adult (41.5%) and 133 of 210 pediatric orders (63.3%) were deemed inappropriate. The most common inappropriate platelet order was for prophylaxis in the absence of bleeding or planned procedure in patients with hypoproliferative thrombocytopenia and a platelet count over 10 x 109 /L (53% of inappropriate orders in adults and 45% in pediatrics). Platelet transfusions ordered with either a preprinted transfusion order set (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.44-2.73) or technologist prospective screening (OR, 1.40; 95% CI, 1.10-1.78) were more likely to be appropriate. CONCLUSION There is a discrepancy between clinical practice and evidence-based platelet guidelines. Broad educational and system changes will be needed to align platelet transfusion practice with guideline recommendations.
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Affiliation(s)
- MaryJane Hill-Strathy
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of St Andrews, Fife, UK
| | - Peter H Pinkerton
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Troy A Thompson
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Alison Wendt
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Allison Collins
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Robert Cohen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Wendy Owens BComm
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Tracy Cameron
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
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38
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Balitsky AK, Liu Y, Van der Meer PF, Heddle NM, Arnold DM. Exploring the components of bleeding outcomes in transfusion trials for patients with hematologic malignancy. Transfusion 2020; 61:286-293. [PMID: 33047878 DOI: 10.1111/trf.16126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 01/08/2023]
Abstract
Clinically significant bleeding in patients with hematologic malignancies is a heterogeneous composite outcome currently defined as World Health Organization (WHO) bleeding Grades 2, 3, and 4. However, the clinical significance of some minor bleeds categorized as WHO Grades 1 and 2 remains controversial. We analyzed the number and frequency of individual signs and symptoms of WHO Grades 1 and 2 bleeds and explored their association with more severe incident bleeds graded as WHO Grades 3 and 4. STUDY DESIGN AND METHODS We aggregated daily bleeding assessment data from three randomized controlled trials conducted in patients with hematologic malignancies that used bleeding as an outcome. Cox proportional hazard regression analysis was used to identify signs and symptoms categorized as WHO Grades 1 and 2 bleeds that were associated with more severe bleeds (Grades 3 and 4). RESULTS We collected data from 315 patients (n = 5476 daily bleeding assessments; 3383 [61.8%] with a bleed documented). A total of 98.3% (3326/3383) were Grade 1 and 2 bleeds and 1.7% (57/3383) were Grades 3 and 4. Grade 1 and 2 bleeds were composed of 20 different bleeding signs and symptoms. Hematuria (hazard ratio, 16.1; 95% confidence interval, 4.4-59.2; P < .0001) was associated with incident Grade 3 or 4 bleeds. CONCLUSION In patients with hematologic malignancy, only hematuria (microscopic and/or macroscopic) was associated with more severe incident bleeds. This findings require validation in independent data sets.
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Affiliation(s)
- Amaris K Balitsky
- Department of Oncology, Division of Malignant Hematology, Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Yang Liu
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Pieter F Van der Meer
- Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands.,Department of Hematology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Nancy M Heddle
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Hematology, McMaster University, Hamilton, Ontario, Canada.,Canadian Blood Services, Hamilton, Ontario, Canada
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Cienfuegos-Pecina E, Ayala-De la Cruz S, Leal-Nava ER, Pérez-Olvera JA, Llaca-Díaz JM, Avilés-Rodríguez LE, Pérez-Chávez F, Díaz-Chuc EA. Assessment of software-derived predictive algorithms for platelet yield and blood cell count after apheresis. J Clin Apher 2020; 36:94-100. [PMID: 33016510 DOI: 10.1002/jca.21846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/22/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Algorithms have been developed to predict the platelet yield after apheresis from the donor's data, as well as the effect on the blood cell count, to extract an acceptable platelet number without affecting the donor. However, the evaluation of these algorithms has not been widely reported. This study aimed to assess the accuracy of the predictive algorithms of the Trima Accel v. 6 blood collection system. METHODS Platelet concentrates (PCs) obtained by apheresis were analyzed. Platelet count and hematocrit were compared pre- and post-apheresis. Calculated post-apheresis platelet count (CPAPC), hematocrit (CPAH), and platelet yield (CPY), and their actual values were correlated. The bias of the algorithms was assessed with Bland-Altman plots, and the prediction of the extraction of single or double platelet products was evaluated. RESULTS Two hundred and seventy-nine PCs were analyzed. Post-apheresis platelet count (PAPC) and hematocrit were decreased. A moderate correlation was observed between CPY and the actual yield, with a negative bias, and a trend to increase alongside the magnitude of the measurements. CPAPC and CPAH were strongly correlated with their actual values without bias. Prediction of single or double platelet product extraction showed a significant agreement with the actual outcomes. CONCLUSIONS The predictive algorithm for the platelet yield showed bias, and a trend to underestimate the actual platelet yields when they are higher. The algorithms for the prediction of the PAPC and hematocrit did not show bias, proving their accuracy. Prediction of a single or double platelet product extraction has a strong agreement with the APY.
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Affiliation(s)
- Eduardo Cienfuegos-Pecina
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Liver Unit, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Sergio Ayala-De la Cruz
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Erika R Leal-Nava
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Jorge A Pérez-Olvera
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Jorge M Llaca-Díaz
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Luz E Avilés-Rodríguez
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Fernando Pérez-Chávez
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Erik A Díaz-Chuc
- Blood Bank, Department of Clinical Pathology, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Nuevo León, Mexico
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Wilde L, Isidori A, Keiffer G, Palmisiano N, Kasner M. Caring for AML Patients During the COVID-19 Crisis: An American and Italian Experience. Front Oncol 2020; 10:1689. [PMID: 32984046 PMCID: PMC7492670 DOI: 10.3389/fonc.2020.01689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022] Open
Abstract
The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the subsequent pandemic have impacted every aspect of oncology care worldwide. Healthcare systems have been forced to rapidly change practices in order to maximize the safety of patients and healthcare providers and preserve scare resources. Patients with acute myeloid leukemia are at increased risk of complications from SARS-CoV-2 not only due to immune compromise related to the malignancy but also due to the acuity of the disease and intensity of treatment. These issues have created unique challenges during this difficult time. In this article, we present the approaches taken by two groups of hematologist/oncologists, one in the United States and one in Italy, who have been caring for acute myeloid leukemia (AML) patients in the face of the pandemic.
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Affiliation(s)
- Lindsay Wilde
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, AORMN Hospital, Pesaro, Italy
| | - Gina Keiffer
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Neil Palmisiano
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Margaret Kasner
- Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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41
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Heddle NM, Cardoso M, Meer PF. Revisiting study design and methodology for pathogen reduced platelet transfusions: a round table discussion. Transfusion 2020; 60:1604-1611. [DOI: 10.1111/trf.15779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/20/2020] [Accepted: 02/15/2020] [Indexed: 01/28/2023]
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Solves Alcaina P. Platelet Transfusion: And Update on Challenges and Outcomes. J Blood Med 2020; 11:19-26. [PMID: 32158298 PMCID: PMC6986537 DOI: 10.2147/jbm.s234374] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/31/2019] [Indexed: 12/29/2022] Open
Abstract
Platelet transfusion is a common practice in onco-hematologic patients for preventing or treating hemorrhages. Platelet concentrates can be transfused with therapeutic or prophylactic purposes. With the aim to help clinicians to take the decisions on platelet transfusion, some guidelines have been developed based on the current scientific evidence. However, there are some controversial issues and available scientific evidence is not enough to solve them. There is little information about what is the best platelet product to be transfused: random platelets or single donor apheresis platelets, and plasma-suspended or additive solution suspended platelets. Platelets are often transfused without respecting the ABO compatibility, but influence of this practice on platelet transfusion outcome is not well established. In the prophylactic platelet transfusion set there are some questions unsolved as the platelet threshold to transfuse prior to specific procedures or surgery, and even if platelet transfusion is necessary for some specific procedures as autologous hematopoietic stem cell transplantation. A challenging complication raised from multiple platelet transfusions is the platelet transfusion refractoriness. The study and management of this complication is often disappointing. In summary, although it is a widespread practice, platelet transfusion has still many controversial and unknown issues. The objective of this article is to review the current evidence on platelet transfusion practices, focusing on the controversial issues and challenges.
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Affiliation(s)
- Pilar Solves Alcaina
- Blood Bank, Hematology Service, Hospital Universitari I Politècnic La Fe, Valencia, CIBERONC, Instituto Carlos III, Madrid, Spain
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43
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Kahn S, Chegondi M, Nellis ME, Karam O. Overview of Plasma and Platelet Transfusions in Critically Ill Children. Front Pediatr 2020; 8:601659. [PMID: 33282804 PMCID: PMC7691248 DOI: 10.3389/fped.2020.601659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/21/2020] [Indexed: 01/19/2023] Open
Abstract
Critically ill children are a unique population who frequently receive plasma and platelet transfusions for both active bleeding and mitigation of bleeding risk. While these products are frequently administered, transfusion indications in this population remain unclear, and practice varies across institutions and providers. In this manuscript, we will outline the current evidence regarding plasma and platelet transfusions for hemostasis in the pediatric intensive care setting. For both products, we will describe the product composition, epidemiology, and product indications and discuss the potential risks and benefits involved with the transfusion. We will also discuss knowledge gaps and future areas of research.
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Affiliation(s)
- Stacie Kahn
- Division of Pediatric Critical Care Medicine, NewYork-Presbyterian, Morgan Stanley Children's Hospital, New York, NY, United States
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care Medicine, Stead Family Children's Hospital- Carver College of Medicine, University of Iowa, Iowa, IA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NewYork-Presbyterian Hospital - Weill Cornell Medicine, New York, NY, United States
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, United States
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Abstract
The evaluation and management of thrombocytopenia is a daily challenge for clinicians in the intensive care unit (ICU). Thrombocytopenia is incredibly common, present in upwards of 60% of ICU patients. Additionally, thrombocytopenia in the critically ill is rarely caused by a single etiology. Several causes of thrombocytopenia in the ICU including heparin-induced thrombocytopenia (HIT) and thrombotic thrombocytopenic purpura demand urgent recognition and intervention. This chapter provides a general overview of thrombocytopenia in the ICU and highlights important diagnostic and management considerations for some of the most common etiologies.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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45
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Gottschall J, Wu Y, Triulzi D, Kleinman S, Strauss R, Zimrin AB, McClure C, Tan S, Bialkowski W, Murphy E, Ness P. The epidemiology of platelet transfusions: an analysis of platelet use at 12 US hospitals. Transfusion 2019; 60:46-53. [PMID: 31850522 DOI: 10.1111/trf.15637] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Using the Recipient and Donor Epidemiology Study-III (REDS-III) recipient and donor databases, we performed a retrospective analysis of platelet use in 12 US hospitals that were participants in REDS-III. STUDY DESIGN AND METHODS Data were electronically extracted from participating transfusion service and blood center computer systems and from medical records of the 12 REDS-III hospitals. All platelet transfusions from 2013 to 2016 given to patients aged 18 years and older were included in the analysis. RESULTS There were 28,843 inpatients and 2987 outpatients who were transfused with 163,719 platelet products (103,371 apheresis, 60,348 whole blood derived); 93.5% of platelets were leukoreduced and 72.5% were irradiated. Forty-six percent were transfused to patients with an International Classification of Diseases, 9th/10th Revision (ICD-9/10) diagnosis of leukemia, myelodysplastic syndrome (MDS), or lymphoma. The general ward and the intensive care unit (ICU) were the most common issue locations. Only 54% of platelet transfusions were ABO identical; and 60.6% of platelet transfusions given to Rh-negative patients were Rh positive. The most common pretransfusion platelet count range for inpatients was 20,000 to 50,000/μL, for outpatients it was 10,000 to 20,000/μL. Among ICU patients, 35% of platelet transfusion episodes had a platelet count of greater than 50,000/μL; this was only 8% for general ward and 2% for outpatients. The median posttransfusion increment, not corrected for platelet dose and/or patient size, ranged from 12,000 to 20,000/μL for inpatients, and from 17,000 to 27,000/μL for outpatients. CONCLUSIONS These data from one of the largest reviews of platelet transfusion practice to date provide guidance for where to focus future clinical research studies and platelet blood management programs.
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Affiliation(s)
| | - YanYun Wu
- Bloodworks Northwest, Seattle, Washington
| | | | - Steven Kleinman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Ronald Strauss
- LifeSource/Institute for Transfusion Medicine, Chicago, Illinois
| | | | | | - Sylvia Tan
- RTI International, Raleigh, North Carolina
| | | | - Edward Murphy
- University of California San Francisco, San Francisco, California
| | - Paul Ness
- Johns Hopkins University, Baltimore, Maryland
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Nixon S, Lieberman L, Atenafu EG, Doherty M, Murray C, Wolfe A, Brandys D, Rowland S, Kwan BY, Yu E, Lechner B, Maze D. Clinical outcomes and transfusion management following intracranial hemorrhage in patients with acute leukemia. Transfusion 2019; 60:269-274. [PMID: 31808560 DOI: 10.1111/trf.15621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/07/2019] [Accepted: 10/14/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is little evidence to guide management of patients with acute leukemia and intracranial hemorrhage (ICH). Predictors of long-term outcome following ICH are unknown. STUDY DESIGN AND METHODS This study included adult patients with acute leukemia and ICH over an 8-year period. The primary outcome was data regarding 90-day mortality. Secondary outcomes included data related to the proportion of patients receiving post-remission therapy and predictors of 90-day mortality. RESULTS ICH occurred in 101 patients; 12 patients died within 72 hours. For the 89 others, 90-day mortality was 40%. Of 43 patients who received induction, 30 achieved remission and 26 received post-remission therapy. Older age (p = 0.03) and higher white count (p = 0.02) at the time of ICH were predictive of inferior survival. During 90-day follow-up, median platelet count was 37 x 109 /L (0-1526 x 109 /L). Lower platelet count during follow-up was predictive of 90-day mortality (p = <0.01). Twenty-one percent of platelet transfusions were provided when the platelet count was less than 10 x 109 /L, 54% between 10 and 29 x 109 /L, and 25% greater than 30 x 109 /L. New or progressive ICH occurred in 23 patients. There was no difference in the median platelet transfusion trigger between patients who had new or progressive ICH and those who did not. CONCLUSION In patients with acute leukemia, survival following ICH is poor. Older age and higher white count is associated with increased mortality, perhaps reflecting higher risk disease. Following ICH in acute leukemia platelet transfusions do not appear to alter the risk of progressive bleeding or mortality.
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Affiliation(s)
- Shannon Nixon
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Lani Lieberman
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Mary Doherty
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Cindy Murray
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Amanda Wolfe
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Danielle Brandys
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Suzanne Rowland
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Benjamin Ym Kwan
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Eugene Yu
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Breanne Lechner
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
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47
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Prodger CF, Rampotas A, Estcourt LJ, Stanworth SJ, Murphy MF. Platelet transfusion: Alloimmunization and refractoriness. Semin Hematol 2019; 57:92-99. [PMID: 32892848 DOI: 10.1053/j.seminhematol.2019.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/14/2019] [Indexed: 12/28/2022]
Abstract
The transfusion of platelets for both prophylaxis and treatment of bleeding is relevant to all areas of medicine and surgery. Historically, guidance regarding platelet transfusion has been limited by a lack of good quality clinical trials and so has been based largely on expert opinion. In recent years however there has been renewed interest in methods to prevent and treat hemorrhage, and the field has benefited from a number of large clinical trials. Some studies, such as platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH) and platelets for neonatal transfusion Study 2 (PLANET-2), have reported an increased risk of harm with platelet transfusion in specific patient groups. These studies suggest a wider role of platelets beyond hemostasis, and highlight the need for further clinical trials to better understand the risks and benefits of platelet transfusions. This review evaluates the indications for platelet transfusion, both prophylactic and therapeutic, in the light of recent studies and clinical trials. It highlights new developments in the fields of platelet storage and platelet substitutes, and novel ways to avoid complications associated with platelet transfusions. Lastly, it reviews initiatives designed to reduce inappropriate use of platelet transfusions and to preserve this valuable resource for situations where there is evidence for their beneficial effect.
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Affiliation(s)
- Catherine F Prodger
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK
| | - Alexandros Rampotas
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK
| | - Lise J Estcourt
- NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK; NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK
| | - Michael F Murphy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK; NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK.
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48
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Estcourt LJ, McQuilten Z, Powter G, Dyer C, Curnow E, Wood EM, Stanworth SJ. The TREATT Trial (TRial to EvaluAte Tranexamic acid therapy in Thrombocytopenia): safety and efficacy of tranexamic acid in patients with haematological malignancies with severe thrombocytopenia: study protocol for a double-blind randomised controlled trial. Trials 2019; 20:592. [PMID: 31615553 PMCID: PMC6792262 DOI: 10.1186/s13063-019-3663-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Patients with haematological malignancies often develop thrombocytopenia as a consequence of either their disease or its treatment. Platelet transfusions are commonly given to raise a low platelet count and reduce the risk of clinical bleeding (prophylaxis) or stop active bleeding (therapy). Recent studies have shown that many patients continue to experience bleeding despite the use of prophylactic platelet transfusions. Tranexamic acid is an anti-fibrinolytic, which reduces the breakdown of clots formed in response to bleeding. Anti-fibrinolytics have been shown to prevent bleeding, decrease blood loss and use of red cell transfusions in elective and emergency surgery, and are used widely in these settings. The aim of this trial is to test whether giving tranexamic acid to patients receiving treatment for haematological malignancies reduces the risk of bleeding or death and the need for platelet transfusions. Methods This is a multinational randomised, double-blind, placebo-controlled, parallel, superiority trial. Patients will be randomly assigned to receive tranexamic acid (given intravenously or orally) or a matching placebo in a 1:1 ratio, stratified by site. Patients with haematological malignancies receiving intensive chemotherapy or stem cell transplantation (or both) who are at least 18 years of age and expected to become severely thrombocytopenic for at least 5 days will be eligible for this trial. The primary outcome of the trial is the proportion of patients who died or had bleeding of World Health Organization grade 2 or above during the first 30 days of the trial. We will measure the rates of bleeding daily by using a short, structured assessment of bleeding, and we will record the number of transfusions given to patients. We will assess the risk of arterial and venous thrombosis for 120 days from the start of trial treatment. Discussion This trial will assess the safety and efficacy of using prophylactic tranexamic acid during a period of intensive chemotherapy and associated thrombocytopenia in people with haematological disorders. Trial registration This study was prospectively registered on Current Controlled Trials on 25 March 2015 (ISRCTN73545489) and is also registered on ClinicalTrials.gov (NCT03136445). Electronic supplementary material The online version of this article (10.1186/s13063-019-3663-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, UK. .,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - Zoe McQuilten
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Gillian Powter
- NHS Blood and Transplant Clinical Trials Unit, Headington, Oxford, UK
| | - Claire Dyer
- NHS Blood and Transplant Clinical Trials Unit, Headington, Oxford, UK
| | - Eleanor Curnow
- NHS Blood and Transplant Statistics and Clinical Studies, Stoke Gifford, Bristol, UK
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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49
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Platelets in Host Defense: Experimental and Clinical Insights. Trends Immunol 2019; 40:922-938. [PMID: 31601520 DOI: 10.1016/j.it.2019.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
Abstract
Platelets are central players in thrombosis and hemostasis but are increasingly recognized as key components of the immune system. They shape ensuing immune responses by recruiting leukocytes, and support the development of adaptive immunity. Recent data shed new light on the complex role of platelets in immunity. Here, we summarize experimental and clinical data on the role of platelets in host defense against bacteria. Platelets bind, contain, and kill bacteria directly; however, platelet proinflammatory effector functions and cross-talk with the coagulation system, can also result in damage to the host (e.g., acute lung injury and sepsis). Novel clinical insights support this dichotomy: platelet inhibition/thrombocytopenia can be either harmful or protective, depending on pathophysiological context. Clinical studies are currently addressing this aspect in greater depth.
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50
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Abstract
Pediatric oncology patients will likely require numerous transfusions of blood products, including red blood cell, platelet, and plasma transfusions, during the course of their treatment. Although strong evidence-based guidelines for these products in this patient population do not exist, given the morbidities associated with the receipt of blood products, practitioners should attempt to use restrictive transfusion strategies.
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