Optimal preprocedural platelet transfusion threshold for central venous catheter insertio…

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Reduction in plasma transfusion after enforcement of transfusion guidelines.
Transfusion. 2011 Apr;51(4):754-61
Authors: Tavares M, DiQuattro P, Nolette N, Conti G, Sweeney J
The majority of fresh-frozen plasma (FFP) i…

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The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis.

Transfusion. 2010 Jun;50(6):1370-83

Authors: Murad MH, Stubbs JR, Gandhi MJ, Wang AT, Paul A, Erwin PJ, Montori VM, Roback JD

BACKGROUND: Plasma transfusion is increasingly performed without clear consensus on indications. We systematically reviewed the literature to summarize the available evidence regarding the benefits and harms of plasma transfusion in common clinical settings. STUDY DESIGN AND METHODS: We searched electronic databases from inception through August 2009. Eligible studies enrolled adult patients transfused with plasma and compared to a control group. Paired reviewers independently assessed studies for eligibility and extracted quality and outcome data. RESULTS: Thirty-seven studies met eligibility criteria, most of which were observational. In patients undergoing massive transfusion, plasma infusion at high plasma : red blood cell ratios was associated with a significant reduction in the risk of death (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.24-0.60) and multiorgan failure (OR, 0.40; 95% CI, 0.26-0.60). However, the quality of this evidence was very low due to significant unexplained heterogeneity and several other biases. In a single retrospective study, plasma transfusion was associated with reduced mortality in anticoagulated patients with intracranial hemorrhage (OR, 0.29; 95% CI, 0.09-0.98). In patients undergoing surgery without massive transfusion, plasma infusion was associated with a trend toward increased mortality (OR, 1.22; 95% CI, 0.73-2.03). Plasma transfusion was associated with increased risk of developing acute lung injury (OR, 2.92; 95% CI, 1.99-4.29). CONCLUSIONS: Very-low-quality evidence suggests that plasma infusion in the setting of massive transfusion for trauma patients may be associated with a reduction in the risk of death and multiorgan failure. A survival benefit was not demonstrated in most other transfusion populations.

PMID: 20345563 [PubMed - indexed for MEDLINE]

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Evidence-based practice guidelines for plasma transfusion.

Transfusion. 2010 Jun;50(6):1227-39

Authors: Roback JD, Caldwell S, Carson J, Davenport R, Drew MJ, Eder A, Fung M, Hamilton M, Hess JR, Luban N, Perkins JG, Sachais BS, Shander A, Silverman T, Snyder E, Tormey C, Waters J, Djulbegovic B, , , , ,

BACKGROUND: There is little systematically derived evidence-based guidance to inform plasma transfusion decisions. To address this issue, the AABB commissioned the development of clinical practice guidelines to help direct appropriate transfusion of plasma. STUDY DESIGN AND METHODS: A systematic review (SR) and meta-analysis of randomized and observational studies was performed to quantify known benefits and harms of plasma transfusion in common clinical scenarios (see accompanying article). A multidisciplinary guidelines panel then used the SR and the GRADE methodology to develop evidence-based plasma transfusion guidelines as well as identify areas for future investigation. RESULTS: Based on evidence ranging primarily from moderate to very low in quality, the panel developed the following guidelines: 1) The panel suggested that plasma be transfused to patients requiring massive transfusion. However, 2) the panel could not recommend for or against transfusion of plasma at a plasma : red blood cell ratio of 1:3 or more during massive transfusion, 3) nor could the panel recommend for or against transfusion of plasma to patients undergoing surgery in the absence of massive transfusion. 4) The panel suggested that plasma be transfused in patients with warfarin therapy-related intracranial hemorrhage, 5) but could not recommend for or against transfusion of plasma to reverse warfarin anticoagulation in patients without intracranial hemorrhage. 6) The panel suggested against plasma transfusion for other selected groups of patients. CONCLUSION: We have systematically developed evidence-based guidance to inform plasma transfusion decisions in common clinical scenarios. Data from additional randomized studies will be required to establish more comprehensive and definitive guidelines for plasma transfusion.

PMID: 20345562 [PubMed - indexed for MEDLINE]

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Clinical outcomes after platelet transfusions in patients with thrombotic thrombocytopenic purpura.

Transfusion. 2009 May;49(5):873-87

Authors: Swisher KK, Terrell DR, Vesely SK, Kremer Hovinga JA, Lämmle B, George JN

BACKGROUND: Reports of deterioration and death after platelet (PLT) transfusions in patients with thrombotic thrombocytopenic purpura (TTP) have led to recommendations that they should not be given except for life-threatening hemorrhage. STUDY DESIGN AND METHODS: Published reports of PLT transfusions in patients with TTP were systematically reviewed and data from the Oklahoma TTP-HUS Registry, an inception cohort of 382 consecutive patients, 1989 through 2007, were analyzed. RESULTS: A systematic review identified 34 publications describing outcomes of patients with TTP after PLT transfusions: 9 articles attributed complications to PLT transfusions, 4 suggested that they may be safe, and 21 articles did not comment about a relation between PLT transfusions and outcomes. Fifty-four consecutive patients from the Oklahoma TTP-HUS Registry were prospectively analyzed. ADAMTS13 activity was less than 10 percent in 47 patients; also included were 7 patients whose activity was not measured but who may have been deficient. Thirty-three (61%) patients received PLT transfusions. The frequency of death was not different between the two groups (p = 0.971): 8 (24%) patients who received PLT transfusions died (thrombosis, 5; hemorrhage, 1; sepsis, 2) and 5 (24%) patients who did not receive PLT transfusions died (thrombosis, 4; hemorrhage, 1). The frequency of severe neurologic events was also not different (p = 0.190): 17 (52%) patients who received PLT transfusions (in 5 of these 17 patients, neurologic events only occurred before PLT transfusions) and 7 (33%) patients who did not receive PLT transfusions. CONCLUSION: Evidence for harm from PLT transfusions in patients with TTP is uncertain.

PMID: 19210323 [PubMed - indexed for MEDLINE]

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Exchange versus simple transfusion for acute chest syndrome in sickle cell anemia adults.

Transfusion. 2009 May;49(5):863-8

Authors: Turner JM, Kaplan JB, Cohen HW, Billett HH

BACKGROUND: There are scant data regarding the relative efficacy of exchange transfusion (XC) versus simple transfusion (ST) for treatment of sickle cell anemia acute chest syndrome (ACS). STUDY DESIGN AND METHODS: Twenty patients who received XC for ACS were compared with 20 ST patients. Hemoglobin (Hb) levels, platelet and white blood cell counts, lactate dehydrogenase (LDH), indirect bilirubin, and temperature were used to assess disease severity. Primary outcome was postprocedure length of hospital stay; secondary outcome was total length of stay. RESULTS: Cohorts were similar with regard to age; sex; prior ACS episodes; echocardiogram results; and antibiotic, bronchodilator, and hydroxyurea use. Maximum temperature recorded was higher in the XC group (39.1 degrees C vs. 38.4 degrees C, p = 0.02), but LDH, WBCs, and indirect bilirubin were comparable. Admission Hb levels were higher for XC (XC 8.6 g/dL vs. ST 7.4 g/dL, p = 0.02) and XC had higher peak Hb levels during hospitalization (10.4 +/- 1.4 g/dL vs. 9.3 +/- 1.0 g/dL, p < or = 0.01). No differences were demonstrable in postprocedure length of stay (XC 5.6 days vs. ST 5.9 days, p = 0.82) or total length of stay (XC 8.4 days vs. ST 8.0 days, p = 0.76). A total of 10.3 +/- 3.0 units were transfused for XC compared to 2.4 +/- 1.2 units for ST (p < 0.001). CONCLUSIONS: Based on postprocedure length of stay or total length of stay, we could not detect a difference in the efficacy of XC compared to ST in populations despite red blood cell product usage fourfold higher in the XC group. We suggest that it is time for an adequately powered, randomized trial to examine the true risk:benefit ratio of XC in ACS.

PMID: 19309475 [PubMed - indexed for MEDLINE]

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Consequences of transfusion of platelet antibody: a case report and literature review.

Transfusion. 2008 Sep;48(9):1981-9

Authors: Pavenski K, Webert KE, Goldman M

BACKGROUND: Passive transfer of platelet (PLT) antibody by blood transfusion can lead to severe thrombocytopenia, bleeding, and an acute transfusion reaction. CASE REPORT: A 49-year-old male on warfarin developed thrombocytopenic bleeding within 2 hours of transfusion with a single unit of fresh-frozen plasma (FFP). The patient’s PLT count on admission was 122 x 10(9) per L. Two hours after transfusion, PLT count has decreased to 5 x 10(9) per L. The patient’s PLT antibody screen by solid-phase enzyme-linked immunosorbent assay was negative and his genotype was HPA-1a/1b. The donor’s genotype was HPA-1b/1b and antibody screen revealed anti-HPA-1a. A lookback investigation identified another case of severe thrombocytopenia after FFP infusion 4 years previously. REVIEW OF LITERATURE: A literature review identified 19 cases of passive transfer of PLT antibody that resulted in thrombocytopenia. The PLT nadir of 7 x 10(9) per L was reached within 6 hours after transfusion with a median time to PLT recovery of 5 days. Transfusion was accompanied by an acute transfusion reaction in 30 percent of recipients. Approximately 75 percent of recipients developed thrombocytopenic bleeding. All cases involved a female donor with a history of pregnancy. High-plasma-volume components accounted for the majority of cases while anti-HPA-1a was the most frequently implicated antibody. CONCLUSION: Unexplained posttransfusion thrombocytopenia should be investigated to rule out passive transfer of PLT antibodies. Implicated donors should be deferred from subsequent donations. Switching to predominantly male plasma for transfusion may lead to reduction in cases of thrombocytopenia due to passive transfer of PLT antibody. Rational use of blood products may further reduce incidence of this complication.

PMID: 18564398 [PubMed - indexed for MEDLINE]

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Platelet transfusions in heparin-induced thrombocytopenia: a report of four cases and review of the literature.

Transfusion. 2008 Oct;48(10):2128-32

Authors: Hopkins CK, Goldfinger D

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a complication of heparin therapy associated with thrombocytopenia and thrombosis. The diagnosis of HIT is based on clinical criteria and laboratory tests, including the serotonin release assay (SRA). Because HIT patients are thrombocytopenic, platelet (PLT) transfusions may be contemplated; however, many published reviews have concluded that PLT transfusions are contraindicated in HIT because they may precipitate thrombotic events. This study reports four patients with clinically suspected HIT who received PLT transfusions without complications, and the literature regarding this subject has been reviewed. STUDY DESIGN AND METHODS: Patients with a SRA ordered for suspected HIT were retrospectively identified. Charts of patients with positive SRAs who received a PLT transfusion when HIT was clinically suspected were reviewed for evidence of PLT transfusion safety and efficacy. A comprehensive search of the published literature regarding PLT transfusions in patients with HIT was conducted. RESULTS: A SRA was performed on 189 patients with suspected HIT. Thirteen patients tested positive and 4 of these received a PLT transfusion. No patient developed a thrombotic complication. All 4 patients had adequate posttransfusion PLT increments. Two of the 3 patients with active bleeding had cessation of bleeding after transfusion. Review of the literature revealed no case of a complication clearly attributable to PLT transfusion. CONCLUSION: Four patients with clinically suspected HIT and a positive SRA were transfused PLTs both efficaciously and safely. These outcomes, combined with the results of the literature review, suggest that PLT transfusions should not be withheld when clinically indicated in patients with HIT.

PMID: 18657085 [PubMed - indexed for MEDLINE]

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