Which complications with the nurse monitor for in a patient who has a platelet count below 100000?

Contraindications

Platelet transfusions are contraindicated in patients with thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), or heparin induced thrombocytopenia (HIT). Although these conditions can have marked thrombocytopenia, they are generally pro-thrombotic and transfusion of platelets may “fuel the fire” if transfused as prophylaxis in the absence of significant bleeding.

Platelet transfusions are controversial in patients with Post Transfusion Purpura, since platelet specific antibodies against high frequency platelet antigens are part of the pathophysiology of this potentially fatal disorder. IVIG is typically a first line therapy and immediate consultation with a hematologist and/or your institutions transfusion medicine physician is highly recommended.

Platelet transfusions in patients with autoimmune destruction of platelets such as ITP should not be transfused in the absence of bleeding because the transfused platelets will be quickly removed similarly to the patient’s own platelets without clinical benefit.

Cautions

If a transfusion reaction is suspected, the transfusion should be stopped, the patient assessed and stabilized, the blood bank notified, and a transfusion reaction investigation initiated. Massive or rapid transfusion may lead to arrhythmias, hypothermia, hyperkalemia, hypocalcemia, dyspnea, and/or heart failure.

Platelet products have an increased risk of significant bacterial contamination/sepsis compared to other blood products because platelets must be stored at room temperature since they rapidly lose function when refrigerated. The risk of sepsis with platelet transfusion is thought to be at least 1:75,000 and the risk of fatal septic platelet transfusion reactions is thought to be at least 1:500,000. Bacterial contamination is more commonly caused by Gram-positive skin flora such as Staphylococcus spp but septic reactions can be due to either Gram-positive or Gram-negative organism contamination. Gram-negative organisms are usually associated with more severe reactions, but broad spectrum antibiotics should be initiated until the causative organism is identified.

Due to the short shelf-life of platelets (5 days from collection), it is not uncommon for blood banks to experience platelet shortages which can delay transfusion for those who have urgent need of transfusion.

If ABO identical platelets are not available, platelets from donors who are ABO plasma compatible may be used. This may occasionally result in suboptimal responses since platelets have a variable amount of ABO antigens, but will not cause clinically significant problems. In large children and adults, ABO incompatible platelets may be issued with only minimal risk of hemolysis, unless large doses of ABO incompatible platelets are transfused. If platelets that are ABO identical or from ABO plasma compatible donors are not available, then efforts to volume reduce or wash the platelets may be considered for neonates if the platelets are not needed urgently. Washing and volume reducing will require significant delays in transfusion and may alter the quantity and quality of the platelet product.

Because all platelet products contain a small amount of RBCs, Rh-compatible platelets should be used if possible to prevent the formation of anti-D in Rh negative individuals. This is particularly important for females that are pregnant or may become pregnant in the future because of the risk of hemolytic disease of the fetus and newborn due to anti-D. Risk of anti-D formation, particularly in this population, can be minimized by providing RhIG within 72 hours of exposure. RhIG is often offered in both intramuscular (IM) and intravenous (IV) suspensions. Use of IV RhIG may be considered if the amount of RhIG needed is large or the patient is at increased risk of injury from IM injections, but is not available in all institutions. One full standard dose of RhIG will be sufficient to cover at least 5 adult doses of pooled whole blood derived platelets or 7 doses of apheresis platelets. Repeat dosing depends on number of Rh-positive platelet doses received and the half-life of RhIG and may need to be considered if it has been greater than 21 days since the last dose of RhIG and additional Rh-positive platelets are to be transfused.

Platelet transfusions may induce formation of HLA antibodies and rarely platelet specific antibodies that may cause immune refractoriness for future transfusions, particularly for patients that require numerous platelet transfusions. The CCI may help determine if the patient has immune refractoriness and its calculation is described in the pharmacology section. Leukocyte reduction may help decrease HLA sensitization. Please see the leukocyte reduced blood products monograph for more complete indications of leukocyte reduced products. Patients with HLA or platelet specific antibodies (HPA-1a) may benefit from HLA matched or HPA-1a negative apheresis platelet transfusions if available. Please see their respective monographs for complete transfusion information.

Patients at increased risk of TA-GVHD should receive irradiated platelet products. For more information regarding indications for irradiation to prevent TA-GVHD, please see the irradiated blood products monograph.

Patients that are CMV seronegative or whose CMV status is unknown and are at increased risk of symptomatic CMV infection should receive CMV reduced risk platelets. Please see the CMV seronegative and leukocyte reduced blood product monographs for more information.

All transfusions must be given via blood administration sets containing 170- to 260-micron filters or 20- to 40-micron microaggregate filters unless transfusion is given via a bedside leukocyte reduction filter. No other medications or fluids other than normal saline should be simultaneously given through the same line without prior consultation with the medical director of the blood bank.

Patient’s should be monitored for signs of a transfusion reaction including vitals pre, during, and post transfusion.

Non-septic infectious risks include transmission of HIV (~1:2 mill), HCV (~1:1.5 mill), HBV (1:300k), HTLV, WNV, CMV, parvovirus B19, Lyme disease, babesiosis, malaria, Chaga’s disease, vCJD.

Consult with blood bank medical director or hematologist if you have questions regarding special transfusion requirements.

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