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* From the Département d’Anesthésie-Réanimation, Hôpital Avicenne, Bobigny;
Site transfusionnel Saint-Antoine, EFS Ile-de-France, Paris;
Service d’Hématologie Biologique, CHU de Nancy, Nancy;
Département d’Anesthésie-Réanimation Chirurgicale, Centre Hospitalier Universitaire Dupuytren, Limoges; Département d’Hématologie/Biologie, CHU Saint Eloi, Montpellier, France.
Address correspondence to: Pr. Charles Marc Samama, Département d’Anesthésie-Réanimation, Hôpital Avicenne, 125, route de Stalingrad, 93009 Bobigny cedex, France. Phone: +33-1-48955591; Fax: +33-1-48955589; E-mail: cmsamama{at}invivo.edu
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Abstract |
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 TOP Abstract IntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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Methods: A panel of experts reviewed and graded the literature on platelet transfusions; recommendations were formulated.
Main findings: Threshold platelet counts (PC) for transfusions in the perioperative context have not been clearly defined and should be determined by the existence of hemorrhagic risk factors. In the case of commonly practiced invasive procedures, the recommendation is to transfuse in order to achieve PC > 50,000·µL–1. In the absence of platelet dysfunction, regardless of the type of surgery, the standard hemorrhagic risk threshold for surgery is 50,000·µL–1. It has not been proven that the risk threshold is different according to the type of surgery. For neurosurgery and ophthalmologic surgery involving the posterior segment of the eye, a PC of 100,000·µL–1 is required. For axial regional anesthesia, a PC of 50,000·µL–1 is sufficient for spinal anesthesia; a PC of 80,000·µL–1 has been proposed for epidurals. During massive transfusion, prophylactic platelet infusion cannot be recommended beyond a loss of two blood volumes in less than 24 hr (Professional Consensus). As for the therapeutic transfusion of plasma and/or platelets, as much as possible, platelet deficit should be documented with test results (PC and fibrinogen) before transfusing. In the event of bleeding, platelet transfusion may precede plasma infusion. However, although this recommendation has been the subject of several professional consensus agreements, it is not based on any randomized studies.
Conclusion: Threshold PC for perioperative transfusions have not been clearly defined and most recommendations are the result of a professional consensus.
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Introduction |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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). Finally, the texts were validated by the "Comité de validation des recommanda-tions et Références médicales de l’AFSSaPS." Members of these three groups are listed in Appendix 1.
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The original, integral version of the recommendations on platelet transfusions can be found on the website of the Agence Française de Sécurité Sanitaire des Produits de Santé: AFSSaPS (French Safety Agency for Health Products): http://www.agmed.sante.gouv.fr/htm/5/rbp/indrbp.htm
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Perioperative platelet transfusions: recommendations |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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Regardless of the hemorrhagic risk assessment:
It is recommended, particularly for surgery, that non-specific methods of reduction of bleeding be used, i.e., (Professional Consensus):
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Platelet transfusion before an invasive procedure or surgery in the event of thrombocytopenia |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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Surgery
In the absence of platelet dysfunction, regardless of the type of surgery, there is no hemorrhagic risk associated with thrombocytopenia alone for PC > 50,000·µL–1. The risk is low for PC between 50,000 to 100,000·µL–1. The standard threshold for hemorrhagic risk for surgery is therefore 50,000·µL–1, including cardiac surgery with cardiopulmonary bypass (Professional Consensus).11–15
There is no proof that the risk threshold is different according to the type of surgery. Nonetheless, for neu-rosurgery and ophthalmologic surgery involving the posterior segment of the eye, a PC of 100,000·µL–1 is required.16
For axial regional anesthesia:
a PC of 50,000·µL–1 is deemed sufficient for spinal anesthesia.
a PC of 80,000·µL–1 has been proposed for epidurals, but other hemorrhagic risk factors must be taken into account, particularly those cited previously, as well as the progressive nature of the thrombocytope-nia.17–21
Aside from cases of massive transfusion, platelet transfusion is considered useful in cardiac surgery and major liver surgery (particularly liver transplantation and portocaval shunt).
In cardiac surgery, therapeutic platelet transfusion is justified if the PC < 50,000·µL–1 (Professional Consensus). Platelet transfusion is justified in the event of microvascular bleeding associated with PC < 100,000·µL–1 (Grade B evidence).
In liver surgery, particularly transplantation, therapeutic platelet transfusion is justified if the PC is 50,000·µL–1 (Grade C). Correction of other factors that foster bleeding such as hypovolemia, hypothermia and anemia is imperative and is an integral part of the platelet transfusion process.
In obstetrics, there is no indication for platelet transfusion in the case of gestational thrombocytope-nia22 in late pregnancy (also known as idiopathic thrombocytopenic purpura (Professional Consensus).
In the event of thrombocytopenia associated with hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP) or preeclampsia, platelet transfusion is recommended immediately before a Cesarean section for a PC of less than 50,000·µL–1 and immediately before vaginal delivery for a PC < 30,000·µL–1 (Professional Consensus).
In autoimmune thrombocytopenic purpura, transfused platelets are very rapidly destroyed, as are the patient’s own platelets. Therefore, there is no indication for platelet transfusion, aside from life-threatening hemorrhagic emergencies (Professional Consensus). In this case, they should be combined with intravenously administered immunoglobulin and high doses of corticosteroids.
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Platelet transfusion during an invasive procedure or surgery in the event of thrombopathy |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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Drug-induced thrombopathy
Drug-induced thrombopathies are the most frequent cause of acquired thrombopathy.23–30 The main drugs involved are platelet function inhibitors and nons-teroidal anti-inflammatory drugs, which have an effect on platelet functionA (depending on the drug and the dosage).
Drugs involved6
The hemorrhagic risks by type of surgery are presented in Appendix 2.
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Role of transfusion
There are no clinical studies validating the benefits of platelet transfusion in reducing the risk of bleeding (prophylactic administration) or in limiting bleeding when it occurs (therapeutic administration) in patients with drug induced thrombopathy. However, this is the only therapeutic option that can be envisaged in the event of severe hemorrhage (Professional Consensus).
Platelet transfusion in the event of massive transfusion
Several definitions for massive transfusion have been proposed:5,31–35
Treatment priorities are:
Prophylactic platelet transfusions based on volume replaced
Prophylactic infusion of platelets is not recommended beyond the replacement of two blood volumes in less than 24 hr (Professional Consensus).
It is important to consider the individual clinical situation and reasons for bleeding. It is likely but not certain that the preventive administration of platelets is not useful if the patient is not bleeding.
Fresh frozen plasma (FFP) should be transfused at the same time as platelets.
Therapeutic platelet transfusion
Abnormal bleeding is bleeding that is unexpected and does not respond either to compression or to electro-coagulation. Although clinical assessment remains an important element in the decision making process, alone is not a sufficient indication for transfusion.
Transfusion of FFP or platelets
As much as possible, it is desirable to document platelet deficits with test results (PC and fibrinogen) before transfusing.
It is also desirable to closely monitor PC and fibrinogen and to begin with platelet concentrates (Professional Consensus). A number of authors suggest using point of care coagulation monitors for surgical bleeding.36
Other elements involved in increased hemostatic problems during massive transfusion
Hypothermia interferes with hemostasis. It is imperative that all available techniques be used to warm the patient as well as the infusion and transfusion products.1,37,38 A drop in hematocrit increases the risk of bleeding, particularly in the presence of thrombocy-topenia. Infusion of packed red blood cells should not be delayed.2–4 Hemostatic problems observed during massive transfusion are increased by shock. Optimization of the patient’s hemodynamic status is an essential objective.39 If a multiple trauma victim with multiple transfusions has a head injury, perioper-ative hemostasis should be controlled even further (earlier infusion of plasma, platelets).
Table II summarizes the available information and proposes a therapeutic transfusion protocol based on the presence/absence of clinical bleeding and the results of laboratory tests.
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APPENDIX 1 |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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Dr NOUYRIGAT Emmanuel, Afssaps
Dr DUMARCET Nathalie, Afssaps
Dr BOURHIS Hean-Henri, Villejuif
Pr CAZENAVE Jean-Pierre, Strasbourg
Pr CLARIS Olivier, Lyon
Dr DAVID Bernard, Afssaps
Dr DECONINCK Eric, Besançon
Dr DENIS Catherine, Afssaps
Dr DJOUDI Rachid, Paris
Pr DUFOUR Patrick, Strasbourg
Dr FOLLEA Gilles, Nantes
Dr KAPLAN-GOUET Cécile, Paris
Pr LECOMPTE Thomas, Vandoeuvre les Nancy
Dr LEFRERE François, Paris
Pr MARIE Jean-Pierre, Paris
Dr MERCADIER Anne, Paris
Pr NATHAN-DENIZOT Nathalie, Limoges
Dr OUNNOUGHENE Afssaps
Pr SAMAMA Marc, Bobigny
Dr SANDID Afssaps
Pr SCHVED Jean-François, Montpellier
Dr SUTTON Laurent, Paris
Dr TRAINEAU Richard, Paris
Dr VEY Norbert, Marseille
Review group
Dr CHABERNAUD Jean-Louis, Clamart
Dr CLUET-DENNETIERE Sophie, Compiègne
Dr DENNINGER Marie-Hélène, Clichy
Dr FAVIER Rémi, Paris
Dr FORESTIER François, Bordeaux
Pr HARDY Jean-François, Montréal
Dr HERNANDORENA José-Xavier, Bayonne
Pr HERVE Patrick, Besançon
Pr IFRAH Norbert, Angers
Pr JANVIER Gérard, Pessac
Pr JOUSSEMET Marcel, Clamart
Dr LAPIERRE Valérie, Besançon
Dr LASNE Dominique, Paris
Dr LEPEU Gérard, Avignon
Pr LONGROIS Dan, Nancy
Pr MILPIED Noël, Nantes
Pr MULLER Jean-Yves, Nantes
Dr PIGNON Bernard, Reims
Pr RIOU Bruno, Paris
Dr SENSEBE Luc, Tours
Pr SIE Pierre, Toulouse
Pr SIMEONI Umberto, Marseille
Pr STEIB Annick, Strasbourg
Pr VAN DER LINDEN Philippe, Jumet
Pr TCHERNIA Gilbert, Le Kremlin Bicêtre
Validation Commmittee
Pr BOUVENOT Gilles, President, Marseille
Pr BERGMANN Jean-François, Vice-President, Paris
Dr CARON Jacques, Lille
Pr CAULIN Charles, Paris
Pr CHOUTET Patrick, Tours
Pr DUPUIS Bernard, Lille
Pr JOLLIET Pascale, Nantes
Dr AMBROSI Pierre, Marseille
Dr ATLAN Pierre, Paris
Pr BANNWARTH Bernard, Bordeaux
Dr CAMELLI Bruno, Paris
Dr CUCHERAT Michel, Lyon
Dr DEMOLIS Pierre, le Kremlin Bicêtre
Dr DENIS Catherine, Afssaps
Pr DIQUET Bertrand, Angers
Dr DUMARCET Nathalie, Afssaps
Dr GUEYFFIER François, Lyon
Dr HANSLIK Thomas, Boulogne Billancourt
Dr LE ROUX Gérard, Epinay sous Sénart
Dr LIEVRE Michel, , Lyon
Dr MEYER François, Afssaps
Pr PETIT Michel, Sotteville-lès-Rouen
Dr REVEILLAUD Olivier, Bièvres
Pr RICHÉ Christian, Brest
Dr ROSTOKER Guy, Afssaps
Dr TREMOLIERES François, Mantes-la-Jolie
Pr TROUVIN Jean-Hugues, Afssaps
Dr WONG Olivier, Paris
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Footnotes |
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A See experts’ conference organized at the initiative of the Société française d’anesthésie et de réanimation (SFAR; the French Society of Anesthesiology and Intensive Care) on "Antiplatelet agents in the perioperative period", available at www.Sfar.org. 
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References |
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TOPAbstractIntroductionPerioperative platelet...Platelet transfusion before an...Platelet transfusion during an...APPENDIX 1References |
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6 Samama CM, Bastien O, Forestier F, et al. Antiplatelet agents in the perioperative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (SFAR) 2001 – summary statement. Can J Anesth 2002; 49(Suppl): S26–35.
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