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Transfusion and Apheresis Science 39 (2008) 29–35

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Platelet transfusions in clinical practice at amultidisciplinary hospital in North India

Anupam Verma *, Prashant Pandey, Dheeraj Khetan, Rajendra Chaudhary

Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226 014, India

Abstract

Specialty wise utilization pattern of platelet concentrates (PLT) over a period of 2 months was evaluated prospectivelyfor appropriateness. Overall 4.87 random donor platelets (RDP) (total 1672) units were issued per request. A total of 1101RDP (66%) were transfused prophylactically against 221 requests (64.4%) while, 571 RDP were transfused for therapeutic(requests = 122, 35.6%) reasons. Twenty-three percent of prophylactic requests and 15% of the therapeutic requisitionswere not justified. Most common reason for unjustified prophylactic transfusion was unavailability of pre-transfusionplatelet count. Concurrent screening of request forms to ensure optimized PLT usage may further decrease platelet misuseat our center.� 2008 Elsevier Ltd. All rights reserved.

Keywords: Platelet transfusion practice; Guidelines; Transfusion trigger; Thrombocytopenia

1. Introduction

The increasing demand for platelet (PLT) trans-fusions in recent years along with increasing aware-ness about associated risks of blood componenttransfusions have focused attention on the needfor continuously analyzing the actual transfusionpractices in hospitals. Platelet transfusions are usedfor prevention or control of bleeding associatedwith deficiency in platelet number or function [1].Strategies should be undertaken to minimize the

1473-0502/$ - see front matter � 2008 Elsevier Ltd. All rights reserved

doi:10.1016/j.transci.2008.05.013

* Corresponding author. Tel.: +91 522 2668700x2506; fax: +91522 2668017.

E-mail addresses: aver@sgpgi.ac.in (A. Verma), pkpandey2007@gmail.com (P. Pandey), dheerajkhetan@gmail.com (D. Khetan),rkcchaud@sgpgi.ac.in (R. Chaudhary).

need for platelet transfusions wherever possibleand appropriately use this precious human resourceas platelets are often in short supply [2]. Inspite ofavailability of so many practice guidelines and rec-ommendations [3–5] to support the clinicians intheir decisions related to platelet transfusions, theresults are less than satisfactory and in fact, plateletsare considered to be one of the most misused bloodcomponent products [6,7].

At our center, the platelet request forms are notmonitored concurrently for indications except forplatelet dosage, which is reviewed by the transfusionspecialist especially during period of shortages forinventory management and thus there remains apossibility of inappropriate use of this scarce com-ponent. In this study we analyzed the utilizationpattern of platelet concentrates at our hospital by

.

30 A. Verma et al. / Transfusion and Apheresis Science 39 (2008) 29–35

different specialties to find out if there was any mis-use so that proper corrective measures can beimplemented.

2. Materials and methods

The study was carried out at 740-bed tertiarycare teaching hospital in the state of Uttar Pradesh,the most populous province of India. This hospitalhas major medical and surgical superspecialities likehematology including bone marrow transplant(BMT), cardiac surgery, gastrosurgery, critical caremedicine (CCM), and nephrology, etc., which aremajor users of platelets. In the present study allthe requests for platelets by various specialties from15th February to 15th April 2005 (2 month dura-tion) were evaluated prospectively.

2.1. Platelet concentrates (PLT)

Platelet concentrates during the study periodwere prepared either from whole blood donation(random donor platelets, RDP) by buffy coatmethod using the optipress II (Baxter,USA) or fromsingle donor by apheresis (single donor platelets,SDP) technique using cell separator CS-3000 (Bax-ter healthcare, USA).

2.2. Data collection and analysis

Patients’ details such as age, gender, pre-transfu-sion platelet counts and other laboratory values

Table 1Criteria for assessment of platelet transfusion appropriateness

Justified usage

Prophylactic indications

I. PLT count <10 � 109/l in stable patients.II. PLT count <20 � 109/l in patients associated with fever, sepsis, sp

III. PLT count <30 � 109/l in patients receiving anti thymocyte glothrombocytopenic purpura (ITP) patients.

IV. PLT count <30 � 109/l in stable premature infants and <50 � 1V. PLT count <50 � 109/l in patients undergoing major surgery/inv

on ventilator.VI. Patients without recent, i.e. within 24 h PLT count who had rec

therapeutic reason.Therapeutic indications

I. Documented platelet function defect in a bleeding patient.II. PLT count <100 � 109/l in patients of cardiopulmonary bypass

in postoperative period or regardless of platelet count if there isIII. Clinically significant non-surgical bleeding (suspected platelet blIV. Bleeding patients without recent, i.e. within 24 h PLT count who

for therapeutic reason.

were obtained from medical records and computerfiles. Details of platelet transfusion support wereobtained from blood bank records. Tentative diag-noses mentioned on the blood requisition formswere used for evaluation. The requisition forms(not the patients) were categorized as therapeuticor prophylactic on the basis of presence or absenceof clinical bleed and analyzed specialty wise for totalnumber of units requested per episode, episodes ofplatelet transfusion per patient, pre-transfusionplatelet count and requirement of special procedureslike irradiation. The following criteria (Table 1)based on our hospital guidelines for platelet transfu-sions were used for analysis.

2.3. Statistical analysis

All the data was entered in computer (MicrosoftExcel, Microsoft Corp., USA) and analyzed usingthe SPSS (ver. 12.0) software.

3. Results

A total of 1746 RDP from 2592 whole blooddonations and 48 SDP from same number of apher-esis donors were prepared during the study period.A total of 352 requisitions for RDP and 48 forSDP were received from 134 patients (including 28outside hospital patients), out of which ninerequests for RDP were not accepted due to inven-tory problem. These patients were transfused a totalof 1672 RDP and 48 SDP units during the study

lenomegaly, or undergoing hematopoietic stem cell transplant.bulin (ATG) therapy or pre splenectomy in adult idiopathic

09/l in a sick infant.asive procedure/massive transfusion or in critically ill patients

eived PLT transfusion(s) within last 2 days at our hospital for

(CPB) having non-surgical, unexpected diffuse bleed during ordiffuse significant bleed within 24 h postoperatively.

eed).received PLT transfusion(s) within last 2 days at our hospital

10

31

32

26

17

38

6

48

6

32

0

10

20

30

40

50

60

Nu

mb

er o

f S

DP

un

its

tran

sfu

sed

ProphylacticTherapeuticTotal

Hematology(n=15)

CCM (n=3) Gastrosurgery(n=2)

Total (n=20)

Number of patients is shown in parentheses

Fig. 1. Platelet (SDP) usage pattern of accepted requisitions.

A. Verma et al. / Transfusion and Apheresis Science 39 (2008) 29–35 31

period. The median age of patients was 31.3 years(range: 2 days–76 years) with male to female ratioof 2.1:1.

Specialty wise RDP usage pattern of acceptedrequisitions is shown in Table 2. Over all, 4.87RDP units were issued per requisition received. Sim-ilarly, specialty wise SDP usage pattern is shown inFig. 1, an average of 2.4 units were transfused perpatient (one per requisition). Hematology depart-ment including BMT unit consumed maximumRDP (n = 950) and SDP (n = 32) followed byCCM department, which consumed 310 RDP and10 SDP units. A total of 1101 (65.8%) RDP units(against 67.4% of the total requests) for prophylac-tic and 571 (34.2%) RDP units (against 32.6% of thetotal requests) were used for therapeutic reasons.

Of the 106 patients from our hospital, 45.3%(n = 48) received a single episode while 19.8%(n = 21) patients received five or more episodes ofRDP transfusions. Repeat platelet transfusions wereprimarily seen in patients of hematology and CCM.Whereas majority (15/16) of the cardiac surgerypatients were transfused one time only. On compar-ing pre-transfusion platelet counts (PC) acrosspatients from different specialties hematologypatients were found to be managed at a lowerthreshold compared to other patients (Table 3).

Over all 65% of prophylactic RDP requisitionshad a pre-transfusion PC below 20 � 109/l and thuswere considered as appropriate. Of the rest 77(�35%) prophylactic requests, pre-transfusionplatelet counts were not available for 24 (10.9%).Out of which eight were considered appropriate asthese were from patients with documented throm-bocytopenic bleeding on previous occasions, the

Table 2Specialty wise platelet usage pattern (RDP) of accepted requisitions (n

Specialty (no. of patients) Requisitions (per patient) RDP issued

Prophylactic

Total Ave

Hematology (46) 183 (4) 754 5.2CCMa (15) 52 (3.5) 185 5.97CVTSb (16) 17 (1) 17 5.7Gastrosurgery (08) 28 (3.5) 46 3.8Nephrology (13) 19 (1.5) 38 3.8Gastromedicine (06) 10 (1.7) 14 4.6Radiotherapy (02) 3 (1.5) 06 2Outside (28) 31 (1.1) 41 2.9Total (134) 343 (2.6) 1101 4.8

a CCM = critical care medicine.b CVTS = cardiovascular and thoracic surgery.

remaining 16 requisitions (including five from out-side our hospital) were considered as inappropriate.Other reasons for inappropriate prophylactic requi-sitions are summarized in Table 4. Thus transfusionof 245 (14.65%) RDP against 51 (23%) prophylacticrequisitions was not justified (Fig. 2).

Appropriateness of therapeutic RDP transfusionwas determined on the basis whether PC wasderanged or not in the presence of clinical bleed.Transfusion of 93 (16.3%) RDP units against 18(14.7%) therapeutic requisitions were consideredinappropriate as pre-transfusion PC in these caseswas not deranged (Fig. 2). Majority of inappropri-ate therapeutic platelet transfusions were to patientswith deranged coagulation profile and thereforeshould have been transfused fresh frozen plasmaand not the platelets.

During the study period, a total of 74 RDP, butno SDP units, were discarded – 47 RDP units due to

= 343)

Therapeutic Total (avg./req)

rage (/request) Total Average (/request)

213 5.6 967 (5.28)125 5.92 310 (5.96)84 6 101 (5.94)48 3 94 (3.4)44 5 82 (4.3)34 4.9 48 (4.8)0 0 06 (02)23 1.4 64 (2.06)571 5.05 1672 (4.87)

Table 3Prophylactic RDP requisitions and pre-transfusion platelet count across patients of different specialties

PLT count(�109/l)

HM,n (%)

CCM,n (%)

CVTS,n (%)

GS,n (%)

NP,n (%)

GM,n (%)

RT,n (%)

OS,n (%)

Total,n (%)

<10 49 (33.8) 06 (19.3) – – – – – 03 (21.4) 58 (26.2)10–20 77 (53.1) 04 (12.9) – – 01 (10) – – 04 (28.5) 86 (38.9)21–50 07 (4.9) 11 (35.5) 01 (33.3) 06 (50) 05 (50) 02 (66.4) 03 (100) 02 (14.3) 37 (16.7)51–100 – 07 (22.5) 01 (33.3) 05 (41.7) 02 (20) – – – 15 (6.8)>100 – 01 (3.2) – – – – – – 01 (0.4)NA 12 (8.2) 02 (6.5) 01 (33.3) 01 (8.3) 02 (20) 01 (33.3) – 05 (35.7) 24 (10.9)

Total 145 31 03 12 10 03 03 14 221

HM = hematology; GS = surgical gastroenterology; GM = medical gastroenterology; NP = nephrology; RT = radiotherapy;OS = outside.

Table 4Reasons of inappropriate prophylactic RDP transfusions

Reasons No. ofrequests(n = 51)

RDP Tx(n = 245)

Unavailability of pre-transfusionPC and/or clinical details

16 74

Pre-transfusion PC > 50 � 109/l 10 43Leukemia with PC > 20 � 109/l 05 28Stable aplastic anemia with

PC > 20 � 109/l06 30

Fever and/or sepsis withPC > 20 � 109/l

04 22

Minor invasive procedure withPC > 50 � 109/l

04 19

Pre splenectomy in ITP withPC > 30 � 109/l

02 11

Chronic DIC without bleed 04 18

Inappropriate23% (n=51)

Total requeRDP

Prophylactic 64.4% (n= 221)

Appropriate77% (n=170)

PC Abn. coag 14.7% (n=18)

Appropriate85.3% (n=104)

PC coag 70.5% (n=86)N↓ ↓

Fig. 2. Appropriateness of RDP transfus

32 A. Verma et al. / Transfusion and Apheresis Science 39 (2008) 29–35

a reactive screen for transfusion transmitted infec-tions, 12 RDP for quality control and 15 RDP unitsfor outdating.

The irradiated platelets (71 RDP and 14 SDP)were demanded for 3 BMT patients and 5 pre-BMTpatients for prevention of graft versus host disease.

4. Discussion

Clinical transfusion audit helps to identify cur-rent pattern of usage and areas of improvement.The transfusion committee should monitor andaudit the blood utilization practices in a hospital.This should be regularly evaluated to improve theblood component utilization and facilitate policymaking in a referral center. Concerns regardingrisks of blood transfusion and non-availability of

sts for

Therapeutic 35.6% (n= 122)

Platelet count, coagulation profile

PC Abn. coag 13% (n=16)

N PC coag 1.6% (n=2)

N

N

Inappropriate14.7% (n=18)

ion: prophylactic versus therapeutic.

A. Verma et al. / Transfusion and Apheresis Science 39 (2008) 29–35 33

blood components make it crucial to optimize plate-let transfusions and reduce wastage. We carried outa prospective study of platelet components usage atour center having major super specialized medicaland surgical branches during 2 month duration.

In this study, unlike other studies for assessmentof platelet usage [7–11], requisition forms and notthe patients were analyzed under two categories –therapeutic or prophylactic on the basis of plateletcount and presence or absence of clinical bleed. Thiswas due to the fact that transfusion in a givenpatient may have been categorized as therapeuticat one time and as prophylactic at some otherinstance, thus making it difficult to allocate patientsbetween these two categories.

Over all, 4.87 RDP units were transfused per req-uisition (per episode) received (Table 2). This is inaccordance with the published guidelines of trans-fusing 1 unit of RDP per 10 kg body weight asmajority of our patient population were adults[12]. In a study from Australia, a pool of 4 unitsof RDP was transfused per episode in 73% of theirpatients [7]. Another analysis of platelet utilizationreported a median of 4.5 units of whole bloodderived platelets being transfused prophylacticallyper episode [11].

Patients with hematological diseases accountedfor 34% of the patients but used 58% of the platelets(Table 2) that is hematology patients were the majorusers of platelet concentrates in our study. Similarfindings have been reported by McCullough et al.[8], in their study of 243 patients and by Schofieldet al., in their study covering 14 Australian hospitals[7].

In our study we have observed that 65.8% ofRDP units were transfused for prophylactic while34.2% were transfused for therapeutic purpose(Table 2). This is also in agreement with publisheddata [8,11].

Of the prophylactic requests for RDP, pre-trans-fusion counts were not available for 8.2% of our in-patients; higher as compared to Eikenboom et al.[13] who reported unavailability of pre-transfusioncounts in 4.3% of their in-patient platelet transfu-sions. Sixty-three percent (of the episodes for whichpre-transfusion counts were available) of the plate-let transfusions were with pre-transfusion countsof more than 10 � 109/l, the most accepted transfu-sion trigger for prophylactic platelet transfusion.Amongst the different specialties, hematologypatients were found to be managed at a lowerthreshold compared to other patients (87% with

pre-transfusion counts below 20 � 109/l, Table 3).A similar proportion of prophylactic transfusionswere reported in a study by Cameron et al. [14]where only 5.3% of patients from hematology–oncology and BMT units were transfused withpre-transfusion counts of 50 � 109/l, while 85.7%had pre-transfusion counts of 20 � 109/l. However,unlike our findings Eikenboom et al. [13] found only68% of their hematology patients being transfusedwith pre-transfusion counts below 20 � 109/l.

In India, blood component therapy is still in itsinfancy, not many are aware of the various guide-lines available for platelet usage and the associatedrisks of platelet transfusion, therefore there aremore chances of inappropriate platelet usage whichleads to waste of the precious human resource thatis already scarce in developing countries. In ourstudy we found that 69/343 (20%) requests wereinappropriate (Fig. 2). This is in accordance withHui et al. [15] who reported that 88% PLT were pre-scribed in an appropriate manner. However, Scho-field et al. [7] from Australia has observed 33%inappropriate platelet transfusions. This differencein appropriate transfusion may be due to differencein patient population or use of different guidelinesfor assessment of appropriateness.

We have observed that inappropriate transfu-sions were more when platelets were transfused forprophylaxis as compared to when transfused to con-trol bleeding (Fig. 2). Higher misuse for prophylac-tic transfusion may be due to the overestimation ofthe immediate risk and the tendency of the cliniciansto transfuse at the safer side of transfusion triggeradjudged for a particular patient. Another reason,that may not be applicable to developed nationswhere there is no shortage of platelet concentrates,is the concern of clinicians to preoccupy the scarceplatelets for their patients, in case the transfusionservice fails to meet the demand when a furtherdecrease in the platelet count of the patient is antic-ipated. This was reflected in increased requisitionsreceived during weekends both for RDP and SDPand during night hours (data not shown).

Not many studies have discussed the misuse ofplatelet transfusion under therapeutic as well as pro-phylactic categories, majority of the workers haveelaborated either on the therapeutic or on the pro-phylactic misuse only. Moreover, the reasons forinappropriate prophylactic platelet transfusion, asshown in our study (Table 4) are also not availableto compare our findings. Majority of these inappro-priate requests belonged to hematology which is

34 A. Verma et al. / Transfusion and Apheresis Science 39 (2008) 29–35

also the main user of platelets at our institute.Another difference in platelet transfusion practiceat our center is that the RDP were given withoutconsideration to ABO and Rh compatibility inalmost all adolescent and adult cases except in twoleukemia patients admitted in hematology wherefive each ABO matched RDP were transfused whenthe platelet counts did not increase with ABO mis-match platelets besides these patients could notafford to have apheresis platelets. SDP were trans-fused only after ABO compatibility in 100% cases.

The PLT expiry rate was relatively low which isreflected by the fact that only 15 of the total 1746RDP prepared during the study period were dis-carded which is much lower compared to expiryrates of 5.8–6.4% quoted by Q-Probes study fromUSA [16]. PLT outdating has been found out tobe the main reason for discarded PLT in variousstudies [16–19].

One interesting finding in this study was theobservation that SDP were transfused within 1 dayand RDP till 5 days after collection. However, dur-ing periods of shortages like during weekends, holi-days the outside demands were given less prioritycompared to our hospital demands for plateletsand RDP with 1–2 days storage were issued. Asper our department policy in view of anticipatedplatelets requirement, RDP were stocked duringperiods of shortages by preparing more number ofplatelets from whole blood donations.

A limitation of our study is the absence of data toallow the inference about the efficacy of PLT trans-fusions, as post-transfusion platelet counts are gen-erally not available for majority of our patientsreceiving RDP. A post-transfusion platelet countshould be obtained within 24 h in all cases to assessthe response to platelet products and to documentany refractoriness to platelet transfusion that actu-ally can bring any change in the treatment policy.In view of our lack of data for platelet transfusionresponse assessment, we are now monitoring ourhematology patients for post-transfusion plateletcounts for SDP where the product yield is readilyavailable as a part of quality control.

In conclusion, information concerning the plate-let preparation, utilization and its wastage was col-lected with a view to improve the existing bloodtransfusion practices and our study shows thatplatelet transfusion therapy at our institute is satis-factory, in the sense, guidelines are being followedin majority of prophylactic as well as therapeuticplatelet transfusions (Fig. 2). This is in contrast to

higher misuse of fresh frozen plasma as shown by aprevious study from our center [20]. This differencein misuse may be due to easy availability of FFPcompared to PLT which have a shorter shelf lifeand is not thought to be suitable for volume replace-ment unlike FFP. The distinctive feature of ourstudy is the analysis of requisition forms and notof the patients which eliminates the indecisivenessof repeatedly allocating same patient into thesetwo different categories, viz. therapeutic and prophy-lactic, during his/her hospital stay. However, thereare still some lacunae in transfusion practice at ourcenter such as lesser SDP usage and inappropriatetransfusions mainly of prophylactic RDP. There isneed for increasing the pool of plateletpheresisdonors and considering use of appropriate pharma-cotherapy in specific situations besides platelet trans-fusion. It is anticipated that periodic lecturesregarding appropriate component usage and concur-rent monitoring of requisition forms can help inimproving rational PLT usage at our center.

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