HOW I DO – Transfusion of Blood Products PART – 1

HOW I DO – Transfusion of Blood Products PART – 1

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we completed Prevention of Cancer series – in total 20 parts. Very enriching and enlightening. Especially what components of lifestyle can we change to reduce risk for ourselves and our patients, family, friends, society as a whole. Cancer is a largely preventable disease. Modern research was highlighted very well and how it tells us that Lifestyle of our Grandparents was the best protection against most common NCDs (non communicable diseases) that we see today, not just cancer but also Heart disease, Stroke, Hypertension, Diabetes, Depression, Infertility, Obesity, Bone disorders, Autoimmune diseases, Allergies and more. And that Mental health and Physical health are so well connected; “Being social” has even more impact on health than doing exercise and being strict with diet. Also, the fact that One Size does not fit all – every individual is different and Aahar, Vihar, Vichar depends on person, age, phase of life, climate etc.

Now our readers want to listen to your thoughts about many common issues they face in the field of Hematology. We still struggle with many questions in this regard. And we don’t have time to go through evidence and discuss controversies. We just want to know what should we do?

Answer: Certainly. I think this is a great topic. And I will try to keep answers as simple as possible. They may not be applicable to each and every type of practice, patient, situation. But I will mainly mention HOW I DO. Medicine is an art and one has to apply that while treating an individual patient. Even I don’t do the same thing for each and every patient, situation.

Que: Thank you for that candid answer. In a short time, we will have rains, followed by dengue and malaria season. Leading to many thrombocytopenia cases. What should we do in terms of platelet transfusion? Is SDP better? When to transfuse? Who to transfuse? What investigation related to transfusion?

Ans: Excellent choice of topic. Very timely also. And very close to the heart of a hematologist. Many unnecessary platelet transfusions happen during this period, leading to shortage of platelets for truly deserving patients. And dengue patients face unnecessary cost, risks, hospitalizations, and families running around trying to arrange blood products. I will highlight only the key points.

1. Dengue patients rarely need platelet transfusion. Only if platelet count is very low i.e. below about 10,000. Or if there is bleeding. When we say bleeding, skin manifestations are not included. Means you don’t transfuse for petechiae, or few bruises.
2. Truly haemorrhagic dengue fever patients are rare. They present with major bleeding, mostly gastrointestinal, within first two days of fever. They mainly have severe ulcerations in GI tract, and they bleed heavily. They need very aggressive treatment, and platelet transfusions alone are rarely enough.
3. Most common patients drop their platelet count few days after first day of fever, generally when fever has resolved. But now platelets drop, due to antibody formation against dengue. They have dropping platelets till about 5-7 days from day one of fever. Then they start recovering platelet by about day 7-10. Almost always by day 10. If late, make sure diagnosis is correct. These patients rarely need platelet transfusion. We transfuse them only if platelet below 10,000 or obvious bleeding. These patients need only supportive care.
4. For those who are in ICU with multiorgan dysfunction, platelet may be kept above 20,000. This is a third group of patients.
5. Means you have Four groups of patients – with different behaviours. Those who are outpatients; inpatients but in wards; inpatients but require ICU for MODS; and hemorrhagic ones in ICU.
6. Once again, be sure with diagnosis. Occasional patients don’t have dengue but leukemia, other infections or other illnesses. Especially during a dengue season, every year we get few patients with wrong label of dengue.
7. When you do need transfusion, SDP and RDP are equal in terms of response. All the guidelines, and most clinical trials (including latest trials from year 2022) advise there is no difference in efficacy. RDP is readily available in most blood banks. Whereas SDP requires special effort by family to find a donor, and also by blood bank. Most patients can be given 4-6 units of RDP in dengue cases, only if indicated.
8. Additionally, currently available machines are very accurate for measuring platelet count. Manual platelet count is NOT required. Hence do not ask your pathologist to do that additional work. Manual platelet count has very very few indications in overall hematology field. Dengue is certainly NOT one of them. All your decisions must be based on machine platelet count.
9. Daily once CBC is sufficient for large majority of patients in hospital. Most certainly for those in ward. Don’t check CBC multiple times a day to decide recovery, or platelet transfusion need, or assess response. Most patients will have antibodies that destroy transfused platelets.
10. I see a number of patients in ICU just for low platelet count. We don’t do that. Only if there is MODS.

June 2, 2024 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com   www.shyamhemoncclinic.com