Perioperative Platelet Transfusions

Aaron Stansbury Hess, M.D., Ph.D.; Jagan Ramamoorthy, M.D.; John Rider Hess, M.D., M.P.H.

Anesthesiology. 2021;134(3):471-479.

Common Platelet Products for Transfusion

There are many different platelet products available in the United States, and they have a range of effects depending on the donor, processing, and storage.^[17] Misunderstanding the composition of platelet products has been implicated in unnecessary transfusions.^[18] The most important questions for the anesthesiologist are, "what is the total platelet content of the product?" and "what volume of plasma is also in the product?" (Figure 1). A single "unit" of "random donor" platelets derived from 500 ml of donor whole blood usually contains at least 55 × 10⁹ platelets in 40 ml of plasma and is stored at 22°C. Transfusing one random-donor unit will raise the recipient platelet count by approximately 5 × 10³ cells/μl, and so it is common to make "pools" of five or six random donor units in approximately 200 ml of plasma. In a stable, nonbleeding, and afebrile adult, transfusing one pool will raise the recipient platelet count by approximately 30 × 10³ cells/μl, but this varies inversely with body mass and area: the platelet count may only rise 15 to 20 × 10³ cells/μl in an obese, 100-kg patient, and may rise 40 to 50 × 10³ cells/μl in a thin, 50-kg one.^[19] Apheresis, or "single-donor" platelets, are a concentrate collected from a single donation and usually contain 3 to 4 × 10^[11] platelets in approximately 280 ml of plasma. This is equivalent to a platelet pool, and transfusing one apheresis unit will also raise the platelet count by approximately 30 × 10³ cells/μl.^[17] Random-donor and apheresis platelets are collected in donor plasma with a coagulation factor activity similar to any other unit of plasma. However, apheresis platelets in the United States are often modified by replacing two thirds of the plasma with an additive solution. This improves platelet lifespan and reduces the rate of minor transfusion reactions but may decrease the acute hemostatic utility of the unit compared to apheresis platelets in plasma.^[20,21] More than half of the platelet units supplied by the American Red Cross (Washington, D.C.) are stored in additive solution, with a system-wide goal of 70% by the end of 2020 (J. Weiss, M.D., American Red Cross, Madison, Wisconsin, email communication, October 2020).

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Figure 1.

An illustration of some of the varieties of platelet products available in the United States, how they are collected, and possible modifications to these products. Anticoagulant solutions are typically buffered salt solutions containing citrate and dextrose. Apheresis platelets in platelet additive solution are commonly referred to as "PAS platelets."

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Table 1. Common Platelet Count Thresholds for Procedures and Platelet Transfusion
Procedure	Platelet Count	Society	Strength of Recommendation/Level of Evidence
Neurologic or posterior ocular surgery	100 × 10³/μl	British Committee for Standards in Haematology⁶³	Strong/low
Epidural catheter placement or removal	75–100 × 10³/μl	Society for Obstetric Anesthesia and Perinatology⁴³	Not graded or endorsed, but acknowledged as common practice
	80 × 10³/μl	British Committee for Standards in Haematology⁶³	Moderate/low
Bleeding after cardiopulmonary bypass	50–100 × 10³/μl	Society of Cardiovascular Anesthesiologists⁴⁹	Not graded
Major nonneuraxial surgery	50 × 10³/μl	AABB (formerly the American Association of Blood Banks)³⁸	Weak/low
	40–50 × 10³/μl	American Society of Clinical Oncology³⁹	Weak/low
Gastrointestinal endoscopy	20 × 10³/μl (50 × 10³/μl for biopsies)	American Society for Gastrointestinal Endoscopy⁶⁴	Not graded
Central line placement	20 × 10³/μl	AABB (formerly the American Association of Blood Banks)³⁸	Weak/low
Bronchoscopy		British Thoracic Society⁶⁵	Weak/low
Prophylaxis of spontaneous bleeding	10 × 10³	AABB (formerly the American Association of Blood Banks)³⁸	Strong/moderate

Table 2. Suggested Important and Influential Studies on Perioperative Platelet Transfusion
Authors	Title	Description	Notes
Slichter et al. ⁹	Dose of prophylactic platelet transfusions and prevention of hemorrhage. (PLADO Trial)	Trial of 1,272 stable medical cancer patients receiving one of three different doses of prophylactic platelets to prevent grade 2 or higher bleeding.	Note figure 1. Risk of grade 2 or higher bleeding in stable patients low and constant at platelet counts between 10 and 80 × 10³ cells/μl.
Avidan et al. ¹⁴	Comparison of structured use of routine laboratory tests or near-patient assessment with clinical judgement in the management of bleeding after cardiac surgery.	Trial of 102 patients receiving postbypass transfusion during coronary artery bypass graft guided by algorithms based on point-of-care vs. laboratory coagulation tests to reduce blood loss and transfusion. Results were compared to a historical control group where transfusion was guided by physician judgment alone.	One of the stronger studies providing evidence for the superiority of laboratory testing–guided transfusion algorithms over physician judgment in postbypass bleeding.
Holcomb et al. ⁵²	Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial.	Trial of 680 severely injured trauma patients predicted to require massive transfusion who received platelets, plasma, and red blood cells in an initially fixed 1:1:1 or 1:1:2 ratio.	Although not the primary outcome, hemorrhagic death was significantly less common in the 1:1:1 arm.
Cardenas et al. ²	Platelet transfusions improve hemostasis and survival in a substudy of the prospective, randomized PROPPR trial.	Subgroup analysis of PROPPR trial participants who received only the first cooler of products.	Although conclusions are limited by the post hoc nature of the analysis, the study strongly suggests that early, empiric platelet administration in massive traumatic bleeding is associated with survival.
Li et al. ⁵⁹	Effect of acetylsalicylic acid usage and platelet transfusion on postoperative hemorrhage and activities of daily living in patients with acute intracerebral hemorrhage.	Trial of 780 patients undergoing emergency craniotomy for hypertensive basal ganglia hemorrhage. Patients on aspirin with an aspirin effect detectable by aggregometry were randomized to receive 0, 1, or 2 units of frozen apheresis platelets.	Frozen apheresis platelets are not currently used in the United States; however, this suggests that there is benefit for laboratory-guided platelet transfusion to reverse bleeding associated with aspirin.
Baharoglu et al. ³	Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral hemorrhage associated with antiplatelet therapy (PATCH): A randomised, open-label, phase 3 trial.	Trial of 190 patients on antiplatelet therapy with supratentorial intracerebral hemorrhage who received platelet transfusion or standard of care.	Patients in the platelet arm had higher death-or-dependence, although this may have been partly due to baseline imbalances.

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Perioperative Platelet Transfusions

Common Platelet Products for Transfusion

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Figure 1.

Figure 1.

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