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Intracranial Hemorrhage and Platelets

Written by: Mediware Consulting and Analytics on Monday, January 9, 2017 Posted in:

We speak often about evidence based indications to support Patient Blood Management (PBM). An effective PBM program requires continual incorporation of the newest knowledge on all blood products including platelets to benefit patients.

The decision to transfuse platelets in the setting of intracranial hemorrhage (ICH) is frequent and certainly provides much angst for our Emergency Medicine and Neurosurgical colleagues.  It has come into the forefront even more recently with the continued rise in the use of anti-platelet medications.

Several studies in this patient population have found hematoma expansion, increased mortality and poor neurocognitive outcomes in patients taking anti-platelet medications.  Other studies have shown no differences in these outcomes.  This variation between studies adds to the dilemma of whether platelet transfusions should be utilized in this clinical scenario.

Even as recently as 2015, meta-analyses and reviews found no compelling evidence to support the use of platelet transfusions.  However, based on small patient numbers, the use of single-drug vs. dual anti-platelet therapy, variable study designs, patient comorbidities, timing of transfusions and lack of consistent platelet function testing, no firm recommendations have been made (see references 1- 12).

As our 2016 year comes to a close, there is finally a randomized controlled trial on this topic.  The much-awaited PATCH Study evaluated the use of platelet transfusion vs. no transfusion in patients taking single or dual anti-platelet therapy with ICH diagnosed within 6 hours of presentation.¹³ In this study, those who received platelet transfusions had an increased hematoma volume/expansion and odds of death.  The authors conclude that “…after the findings of the PATCH trial, platelet transfusion cannot be recommended…”

The 2016 published guidelines from NeuroCritical Care, although released prior to the publication of the PATCH trial, also provide some thoughtful  recommendations.¹ These PBM guidelines recommend against platelet transfusion with anti-platelet medication-associated ICH in patients not undergoing neurosurgical intervention regardless of the medication(s), platelet function test result, volume of ICH or neurologic exam.  Those patients necessitating an urgent intervention should receive a single adult dose of platelets if a platelet function test reveals dysfunction or if this testing is not available.  Those with normal function or known resistance to their drug should not be transfused.  Note should be made of the reference to a single adult dose (mirroring the view for single-unit RBC transfusion practice) and the incorporation of platelet function testing to help with decision-making.  This guideline also comments on the use of adjuvant therapies in the bleeding patient such as DDAVP.  Once again, we see that the Pharmacy often possesses alternatives that can aid in decreasing the need for transfusion and potential transfusion-associated adverse events.

Do I believe these current studies and consensus publications will turn your Neurosurgeons and Emergency Departments immediately on their heels?  Likely not, and more studies are certainly needed, however, this literature can open the door to the conversation, ultimately providing safer, more effective care for our patients.  Constant review and incorporation of the newest knowledge into our practice of Patient Blood Management will and should take our programs to the next level.

References:

  1. Creutzfeldt CJ J Stroke Cerebrovasc Dis 2009; 18: 221
  2. Downey DM The Amer Surg 2009; 75: 1100
  3. Sansing LH Neurology 2009; 72: 1397
  4. Campbell PG World Neurosurg 2010; 74: 279
  5. Washington CW J Trauma 2011; 71: 358
  6. Ducruet AF Neurolog Res 2012; 32: 706
  7. Nishijima DK J Trauma Acute Care Surg 2012; 72; 1658
  8. Naidech AM Neurocrit Care 2012; 16: 82
  9. Batchelor JS BMJ Open 2012; 2: e000588
  10. Martin M Ann Emerg Med 2013; 61; 58
  11. Joseph B et al. J Trauma Acute Care Surg 2013; 75; 990
  12. Leong L & David T J Emerg Med 2015; 49: 561
  13. Baharoglu M et al Lancet 2016; doi: 10.1016/SO140-6736(16)30392-0
  14. Frontera J Neurocrit Care 2016; 24: 6

Author: Carolyn Burns, MD