Platelet Transfusion in Critically Ill Patients
Khaled Mohamed Abd El Naeem;
Abstract
Platelets play a crucial role in hemostasis. Platelet dysfunctiondue to congenital and acquired etiologies is one of the most common causes of bleeding encountered in clinical practice. Bleeding manifestations are characterized by mucocutaneous bleeding like bruising, nose bleeding and menorrhagia, and bleeding after hemostatic stress, such as after tonsillectomy and adenoidectomy, dental extraction, and, rarely, post-partum.
The many comorbidities in the severely ill patient affect platelet homeostasis, and, consequently, thrombocytopenia is very common in critically ill patients treated in the intensive care unit (ICU).Thrombocytopenia is usually defined as a platelet count of >150 x109/L, whereas severe thrombocytopenia is considered as platelet counts > 50 x 109/L.
The prevalence of thrombocytopenia on admission to the ICU ranged from 8.3% to 67.6%. The incidence of thrombocytopenia acquired during the course of the ICU stay ranged from 13.0% to 44.1%. In addition platelets play a critical role in normal hemostasis. They are activated when exposed to disrupted endothelium leading to platelet aggregation and formation of a hemostatic plug. In addition, the platelet membrane acts as a binding surface for the initiation and perpetuation of the coagulation cascade.
Both quantitative and qualitative (platelet dysfunction) platelet disorders can lead to an increased risk of bleeding that can be potentially life threatening.Dysfunctional platelets despite normal counts can occur due to many congenital and acquired causes. Congenital causes as Bernard-Soulier syndrome,storage pool diseases and Glanzmann’sthrombastheniaetc. Acquired causes as Therapeutic antiplatelet agents, Liver disease and Uremia etc.
The mechanism of low platelet counts in ICU is often multifactorial resulting from decreased production, dilution, sequestration, and increased destruction.
The most common causes of thrombocytopenia in ICU are DIC, sepsis, immune thrombocytopenia, drug-induced thrombocytopenia (DITP), thrombotic micro-angiopathy, post transfusion purpura and hypothermia. Nearly all studies analyzing thrombocytopenia as a prognostic marker in ICU patients found an inverse correlation of the platelet count with the risks for a prolonged ICU stay and mortality. We reviewed specific management strategies that clinicians can follow in evaluating and treating thrombocytopenia in the critically ill patient.
The risk of bleeding is high with severe thrombocytopenia and is enhanced in intensive care patients with mild or moderately low platelet counts when additional factors are present that interfere with normal hemostatic mechanisms (e.g., platelet function defects, hyperfibrinolysis, invasive procedures, or catheters). Even if not associated with bleeding, low platelet counts often influence patient management and may prompt physicians to withhold or delay necessary invasive interventions, reduce the intensity of anticoagulation, order prophylactic platelet transfusion, or change anticoagulants due to fear of heparin-induced thrombocytopenia.
Hemostasis depends on an adequate number of functional platelets, together with an intact coagulation (clotting factor) system.
Platelet transfusion therapy has major contributions to thecare of a variety of patients. Indications include prevention ofbleeding, active bleeding and special situations as immunethrombocytopenia, DIC, cardiac surgery and HIT. New guidelinesfor platelet transfusions trigger approved; Platelet selectionaccording to ABO compatibility, Rhesus D antigen (RHD)compatibility and cytomegalovirussero-negative platelets, isimportant to avoid adverse effects. Adverse effects include febrilereaction, bacterial contamination of platelet concentrates,urticarial reactions, transfusion-related acute lung injury(TRALI), post-transfusion purpura, hypotensive reactions duringplatelet transfusions, graft versus host disease (GVHD) and lackof response to platelet transfusion (refractoriness) which has aspecial practical strategy to deal with.
The many comorbidities in the severely ill patient affect platelet homeostasis, and, consequently, thrombocytopenia is very common in critically ill patients treated in the intensive care unit (ICU).Thrombocytopenia is usually defined as a platelet count of >150 x109/L, whereas severe thrombocytopenia is considered as platelet counts > 50 x 109/L.
The prevalence of thrombocytopenia on admission to the ICU ranged from 8.3% to 67.6%. The incidence of thrombocytopenia acquired during the course of the ICU stay ranged from 13.0% to 44.1%. In addition platelets play a critical role in normal hemostasis. They are activated when exposed to disrupted endothelium leading to platelet aggregation and formation of a hemostatic plug. In addition, the platelet membrane acts as a binding surface for the initiation and perpetuation of the coagulation cascade.
Both quantitative and qualitative (platelet dysfunction) platelet disorders can lead to an increased risk of bleeding that can be potentially life threatening.Dysfunctional platelets despite normal counts can occur due to many congenital and acquired causes. Congenital causes as Bernard-Soulier syndrome,storage pool diseases and Glanzmann’sthrombastheniaetc. Acquired causes as Therapeutic antiplatelet agents, Liver disease and Uremia etc.
The mechanism of low platelet counts in ICU is often multifactorial resulting from decreased production, dilution, sequestration, and increased destruction.
The most common causes of thrombocytopenia in ICU are DIC, sepsis, immune thrombocytopenia, drug-induced thrombocytopenia (DITP), thrombotic micro-angiopathy, post transfusion purpura and hypothermia. Nearly all studies analyzing thrombocytopenia as a prognostic marker in ICU patients found an inverse correlation of the platelet count with the risks for a prolonged ICU stay and mortality. We reviewed specific management strategies that clinicians can follow in evaluating and treating thrombocytopenia in the critically ill patient.
The risk of bleeding is high with severe thrombocytopenia and is enhanced in intensive care patients with mild or moderately low platelet counts when additional factors are present that interfere with normal hemostatic mechanisms (e.g., platelet function defects, hyperfibrinolysis, invasive procedures, or catheters). Even if not associated with bleeding, low platelet counts often influence patient management and may prompt physicians to withhold or delay necessary invasive interventions, reduce the intensity of anticoagulation, order prophylactic platelet transfusion, or change anticoagulants due to fear of heparin-induced thrombocytopenia.
Hemostasis depends on an adequate number of functional platelets, together with an intact coagulation (clotting factor) system.
Platelet transfusion therapy has major contributions to thecare of a variety of patients. Indications include prevention ofbleeding, active bleeding and special situations as immunethrombocytopenia, DIC, cardiac surgery and HIT. New guidelinesfor platelet transfusions trigger approved; Platelet selectionaccording to ABO compatibility, Rhesus D antigen (RHD)compatibility and cytomegalovirussero-negative platelets, isimportant to avoid adverse effects. Adverse effects include febrilereaction, bacterial contamination of platelet concentrates,urticarial reactions, transfusion-related acute lung injury(TRALI), post-transfusion purpura, hypotensive reactions duringplatelet transfusions, graft versus host disease (GVHD) and lackof response to platelet transfusion (refractoriness) which has aspecial practical strategy to deal with.
Other data
| Title | Platelet Transfusion in Critically Ill Patients | Other Titles | نقل الصفائح الدموية في المرضى ذوي الحالات الحرجة | Authors | Khaled Mohamed Abd El Naeem | Issue Date | 2015 |
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