An Octogenarian Patient Of Intracapsular Neck Of Femur Fracture With Pre-operative Big Challenge Thrombocytopenia

Pre-operative Thrombocytopenia
collection and preparation of sdp single donor platelets
Hb, pt inr, platelet counts
apheresis
principle
donation criteria
sdp vs rdp
guidelines for platelet transfusion
etiologies of thrombocytopenia
isolated thrombocytopenia management
first line second line management

1. An Octogenarian Patient Of Intracapsular Neck Of Femur Fracture With Pre-operative Big Challenge Thrombocytopenia Presenter- Dr. Shiny PG JR 2 nd Year Dept. Of Immunohematology & Blood Transfusion

2. Requisition on 24/01/2024 We received a requisition for 2 units of single Donor Platelets for an 81 years old Male patient, at 4.20 pm. Indication- Pre-operative Thrombocytopenia Pre-transfusion platelet count- 40,000/ uL

3. ABO-Rh typing ABO-Rh typing- O positive

4. Collection and Preparation Donor selection and screening Time taken for procedure Yield Volume Quality control SDP 1 Family was unable to arrange donor, so, donors were requested by local NGOs Pre-collection screening was done including CBC and TTI screening of the donors. 67 minutes 4.0 x 10 11 286 ml Platelets- 14,90,000/ uL WBC- 0.00/ uL RBC- 0.01/ uL TTI tested by Chemiluminescence SDP 2 76 minutes 4.0 x 10 11 294 ml Platelets- 13,38,000/ uL WBC- 0.00 RBC- 0.00 TTI tested by Chemiluminescence

5. Transfusion Both SDP products were requested together Issued on 26/01/2024 at 3.45 am SDP 1- Transfused on 26/01/2024 at 4 am. SDP 2- Transfused on 26/01/2024 at 5 am. TTI tested by Chemiluminescence ABO compatible No Transfusion reaction was reported on both transfusions.

6. PRBC Transfusion 1 st PRBC Transfusion 27/01/2024 2 nd PRBC transfusion 01/02/2024 Indication- Hb 8.5 gm/dl 370 mL O positive PRBC at 5.55 pm DOC- 14/01/2024 PTT- Compatible No transfusion reaction reported Indication- Hb 6.9 gm/dl 380 mL O positive PRBC at 10.46 pm DOC- 15/01/2024 PTT- Compatible No transfusion reaction reported

7. Follow up at Blood Centre Antiglobulin tests- Negative Antibody screening- Negative

8. Platelet count, Hb, INR trends Pre-transfusion 24/01/2024 1 hour increment Post 2 SDP transfusions 26/01/2024 24 hours increment 27/01/2024 After 1 st PRBC Transfusion 28/01/2024 29/01/24 to 01/02/24 After 2 nd PRBC Transfusion 02/02/2024 Platelet count (per uL ) Hb (gm/dl) 40000 9.3 1,64,000 8.0 1,60,000 8.5 1,23,000 9.6 1,05,000 to 89000 to 71000 to 55000 8.8 to 8.1 to 7.5 to 6.9 50,000 to 75,000 8.0 to 8.2 Increment- 62000/ uL per SDP unit transfusion 1 gm/dl per PRBC transfusion So, not a case of transfusion refractoriness

9. Apheresis In apheresis, blood is withdrawn from a donor in an anticoagulant solution and separated into components. One (or more) component is/are retained, and the remaining constituents are returned to the donor. In a plateletpheresis procedure, donor’s platelet are removed from whole blood, and the remaining components are returned back to the donor.

10. Principle The anticoagulated blood from the donor is pumped into a rotating bowl , separating the incoming blood by centrifugal force in such a way that red cells move to periphery and plasma to the inside of rotating bowl and white cells and platelets layer between the red cells and plasma. A portion of the donor’s platelets and some plasma is removed with the return of the donor’s RBCs, WBCs , and remaining plasma. A plateletpheresis procedure usually takes 6-8 cycles to collect a therapeutic dose.

11. Routine procedure takes 1-1.5 hours. Storage- 5 days on platelet agitator at 22 degrees .(the day of collection of platelets- day zero)

12. Donation Criteria 1. Donor weight >50 Kg , Age- 18 to 60 years 2. The interval between procedures should be at least 48 hours. A donor should not undergo the procedure more than 2 times a week or 24 times a year . After the whole blood donation, the donor should be accepted only after 28 days of interval. 3 . P latelet count and Hb must be more than 150,000/ μl and > 12.5 g/dl before starting the procedure. 4. Double unit apheresis can be taken in donors whose platelet count is more than 250,000/ ul and weight more than 60kg and those who are not 1 st time apheresis donors.

13. SDP vs RDP SDP RDP Collection obtained from an apheresis donation Platelets derived from whole blood the platelet product Volume 50-70 mL >200 mL Yield and Increment one SDP unit, containing a minimum of 3x10 11 platelets, should increase an adult’s platelets by 30,000 to 70,000/ μL one RDP unit, containing at least 5.5x10 10 platelets, should increase platelet count by 5,000 to 10,000/ μL . Advantages More platelet increment Safer Leucoreduced Cost effective ABO incompatible units can be transfused Disadvantages Expensive Same blood group apheresis donor required for preparation 5-6 folds higher risk of bacterial contamination 2 folds higher risk of TTIs as compared to SDPs

14. Age Age-specific in older adults include enhanced platelet aggregation and increased fibrinogen, factor V, and von Willebrand factor to maintain normal hemostasis in age-related changed organ and vasculature systems- chronic medications, Loss of subcutaneous tissue Splenomegaly causes platelets to pool inside of the spleen and cause thrombocytopenia (low platelets available in peripheral blood). Chronic disorders (HTN, NSTEMI) Decreasing platelet counts trend may be a consequence of platelet hyperdestruction secondary to abnormal platelet activation in a deteriorating disease state. In addition, the severity of thrombocytopaenia may be a marker of more severe right heart failure and abnormal haemodynamics .

15. References McMahon BJ, Kwaan HC. Thrombocytopenia in older adults. Seminars in thrombosis and hemostasis . 2014;40(6):682-687. 2. Aster RH, Curtis BR, McFarland JG, Bougie DW. Drug-induced immune thrombocytopenia: pathogenesis, diagnosis, and management. Journal of thrombosis and haemostasis : JTH. 2009;7(6):911-918. https://www.ncbi.nlm.nih.gov/books/NBK537240/#:~:text=Immune%20thrombocytopenic%20purpura%20(ITP)%20is%20an%20autoimmune%20disease%20characterized%20by,autoantibodies%20sensitize%20the%20circulating%20platelets . Principles and Practice of Transfusion Medicine, Dr. R. N. Makroo , 2 nd edition Harmening DM. Modern Blood Banking & Transfusion Practices 7 th edition THANKYOU