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EFFECTIVENESS OF PLATELET TRANSFUSION IN DENGUE PATIENTS IN A
TERTIARY CARE HOSPITAL
Original Article
VIJAY ANAND V.*, ANKIT SHARMA
Immunohematology and Blood Transfusion (IHBT), Sawai Mansingh Medical College, Jaipur, India
*Corresponding author: Vijay Anand V.; *Email: vijayanand1103@gmail.com
Received: 20 Apr 2023, Revised and Accepted: 11 Jun 2023
ABSTRACT
Objective: Dengue has been emerging as rapidly spreading and dreaded mosquito-borne disease caused by the bite of Aedes Aegypti Mosquito.
Clinical features are variable and presents with Dengue fever or Dengue Hemorrhagic fever or more severe Dengue shock syndrome.
Thrombocytopenia is presenting feature in all Dengue cases and some often presents with bleeding. Platelet transfusions are given in patients with
haemorrhagic symptoms. While medical fraternity globally recognizes the role of platelet transfusion in the management of hospitalized dengue
patients the exact indications and situations in which these are to be transfused may vary. Since there is inherent risk associated with the
transfusion of blood/blood-component, it is imperative for each institution (or country) to lay their own criteria for transfusion of these blood
components. The present study was conducted to lay precise criteria and transfusion trigger for platelet transfusion in our setup.
Methods: The present study was conducted on 225 serologically confirmed dengue patients admitted at sawaimansign Hospitals between 1" of
August to 30th of November 2022. Clinical data, reports of hematological investigation, platelets requirements and data obtained from SHealth
services.
Results: In the serologically confirmed cases, the prevalence of thrombocytopenia (count less than 100,000/cumm) was 84.88% on admission and
bleeding was recorded in 22 (9.7%) patients. About 96 (42.6%) patients of dengue cases received platelet transfusion. Among them 47 (20.88%)
patients had a platelet count<20,000/cumm, 43 (19.11%) had a platelet count in the range of 21-40.000/cumm, while 6 (2.66%) patients had the
platelet count in between 41 and 50.000/cumm. Out of 49 patients with a platelet count>20,000/cumm, 18 patients had hemorrhagic
manifestations such as petechiae, gum-bleeding, epistaxis, etc., which necessitates the use of platelet transfusion. However, 31 patients received
inappropriate platelet transfusion.
Conclusion: This study suggests that bleeding occurs more often in patients with severe thrombocytopenia. High-risk patients having platelet
count<20,000/cumm and risk of bleeding require urgent platelet transfusion. Patients with a platelet count 21-40,000/cumm are in moderate risk
and require platelet transfusion only if they have any haemorrhagic manifestations and other superadded conditions.
Keywords: Platelet transfusion, Dengue
© 2023 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (https://creativecommons.org/licenses/by/4.0/)
DOI: https://dx.doi.org/10.22159/ijcpr.2023v15i4.3022. Journal homepage: https://innovareacademics.in/journals/index.php/ijcpr
INTRODUCTION
Dengue is the most rapidly spreading mosquito borne viral disease
in world and an estimated 50 million dengue infections occur
annually [1]. The south East Asian countries like India, Indonesia,
Myanmar and Thailand are at highest risk of Dengue
Fever/Dengue Haemorrhagic Fever. Dengue is viral disease caused
by dengue virus with four serotypes DEN-1 to DEN-4 of flavivirus
family transmitted through Aedes Aegypti mosquito [2]. A platelet
count of less than 100,000/μl is one of the diagnostic criteria for
dengue haemorrhagic fever [4]. However, severe
thrombocytopenia can be seen in both dengue fever and dengue
haemorrhagic fever. There is a significant negative correlation
between disease severity and platelet count [5]. Although low
platelet count and hypofibrinogenemia are the two most
prominent haemostatic defects responsible for bleeding in dengue
infection [6], thrombocytopenia and coagulation abnormalities do
not reliably predict bleeding in dengue infection [7, 8]. Causes of
thrombocytopenia include both bone marrow suppression and
platelet destruction. Immune complex-mediated platelet
destruction is probably the most important factor contributing to
thrombocytopenia in dengue infection.
The present study thus aims to study the effectiveness of platelet
transfusions in management of dengue patients with Dengue
haemorrhagic fever and Dengue shock syndromes and their
treatment outcome dengue patients with Dengue haemorrhagic
fever and Dengue shock syndromes and their treatment
outcome.
MATERIALS AND METHODS
This was a retrospective study conducted at SMS Medical college
hospital, Jaipur, on adult patients with dengue fever confirmed
positive by dengue serological Rapid test kits. The cases were
diagnosed and categorized as per WHO criteria into 1) Dengue fever
2) Dengue Haemorrhagic fever and 3) Dengue shock syndrome
based on severity of disease, bleeding manifestations, haematocrit
and thrombocytopenia. The age of patient, duration of fever before
admission, result of dengue serological test, haematocrit, platelet
count on admission during hospitalization, Presence of
haemorrhagic manifestation like petechiae, hematemesis, melena,
gum bleeding were recorded. DGHS guidelines for indication, dose
and monitoring of response for platelet transfusion were followed.
Blood samples were collected in EDTA anticoagulated vials, and platelet
counts were measured by automated count analyzer. In order to avoid
pseudo-thrombocytopenia, citrated samples were used to repeat platelet
counts if EDTA-induced platelet clumping was seen [13]. Platelet counts
were obtained at baseline (P0), 24 h (P24), and 72 h (P72) for all
patients. Additionally, platelet counts were also obtained within 10 min
to 1 h post transfusion (P1) for the treatment group (fig. 1).
Corrected count increment (CCI) was determined using the
following formula:
CCI = (PPI × BSA (m2)) × 1011/number of platelets transfused …. (1)
PPI represents the post-transfusion platelet increment (post-
transfusion platelet count minus pre-transfusion platelet count), and
International Journal of Current Pharmaceutical Research
ISSN- 0975-7066 Vol 15, Issue 4, 2023
V. A. V. & A. Sharma
Int J Curr Pharm Res, Vol 15, Issue 4, 40-42
41
BSA is the body surface area measured in square meters. We used
Mosteller formula for calculating BSA.
We measured PPI and CCI at 10 min to 1 h post-transfusion in the
treatment group. Based on their responsiveness to platelet
transfusion, patients in the treatment group were further divided
into responders and non-responders. Patients with PPI*10,000/μl
and/or CCI*5,000/μl 1 h post-transfusion were considered
responders; the rest were considered. s. Patients having platelet
count>20,000 per µl. in the absence of bleeding manifestations were
considered to have received inappropriate platelet transfusion.
RESULTS
Of the 242 clinically suspected dengue patients, 225 were positive
for anti-dengue IgM antibodies. Among the of 225 serologically
positive dengue cases, 199 (88.4%), 21 (9.3%) od 5 (2.2%) were
classified as DF, DHF and DSS, respectively accolg to WHO
classification. The involvement of all age groups, especially an adult
predominance, was observed. The mean age of the dengue patient
was 27 y and the most belonged to the 21-30 y age group, which
included 73 patients (32.44%), [fig. 1]. Platelet count
of<100,000/cumm was detected in 191 (84.88%) patients and
haematocrit value of>45% was observed in 32 patients (14.22%) at
the time of admission. Hemorrhagic manifestations were present in
34 (15.11%) patients of dengue infection, which mainly included
petechiae-21 (9.3%) patients, epistaxis-6 (2.7%) patients,
haematemesis-5 (2.22%) patients, melaena-3 (1.33%) patients, gum
bleeding-8 (3.55%) patients. Bleeding occurred more often in
patients with severe thrombocytopenia and was frequent when the
platelet count was below 20,000/cumm [table 1]. About 96 among
the 225 serologically confirmed patients (42.60%) received platelet
transfusion therapy. Among them 58 patients were male and 38
patients were female. About 79 (39.69%) of the 199 patients with
dengue fever required platelet transfusion. Similarly among the 21
DHF patients, 15 (71.42%) patients and out of 5 DSS patients only 2
(40%) patients required platelet transfusion.
All the 10 patients having platelet count<10,000/cumm had received
platelet transfusion. Out of 40 patients having platelet count in
between 11-20,000/cumm, 37 patients received platelet transfusion
whereas 43 patients out of 77 had received platelet transfusion that
were having the platelet count in the range of 21-40,000/cumm. 6
patients having platelet count in the range of 41-100,000/cumm
received platelet transfusion. None of the 19 (8.4%) patients having
platelet count>100,000/cumm, received platelet transfusion. Out of
49 patients having platelet count>20,000/cumm, and receiving
platelet transfusion, 18 patients had haemorrhagic manifestations
while 31 patients had no haemorrhagic manifestations.
Most of the patients receiving platelet transfusion recovered
completely and were discharged within 2-5 d of their last platelet
transfusion. The platelet count had picked up considerably and the
average platelet count of the patients at discharge who received
platelet transfusion were 95,000/cumm.
Besides platelet transfusion, FFP and PRC were also transfused to the
dengue patients. Out of 12 patients who were transfused with FFP, seven
had abnormal PT/PTT, INR and four patients were transfused with FFPs
along with platelet transfusion. Five dengue patients had received PRC
transfusion whose hemoglobin level was<8.0 gm/dl.
During the study period there were 50 patients whose platelet count
was<20,000/cumm. Out of these, 47 were given platelet transfusions
and there were three patients with a platelet count between
15,000/cumm and 20,000 who did not bleed and improved without
any transfusion.
There was one patient who was suffering from falciparum malaria
along with dengue fever. Only two patients died during
hospitalization (mortality being 0.88%). One had additional clinical
manifestations like septicaemia, while the other had severe bleeding
with multi-organ failure and both belonged to 31-40 y age group.
DISCUSSION
Dengue fever is a major public health problem in India. This study
showed that the majority of dengue cases were adult with the largest
proportion in the age group of 21-30 y. This is in accordance with
the findings of Pervin et al. Thrombocytopenia was found in 84.88%
of the confirmed cases on admission. This prevalence is comparable
with the findings of Chairulfatah et al. who found a similar incidence
of 83% in hospitalized dengue patients. Bleeding occur significantly
more often in patients with severe thrombocytopenia most often in
patients with a platelet count less than 20,000/cumm which is
similar to the finding of Shivbalan et al. but Chairulfatah et a l. found
significant bleeding in patients with thrombocyte count less than
15,000/cumm. Bleeding during DHF may result from a combination
of factors such as thrombocytopenia, coagulation defects and
vasculopathy [2]. Therefore before platelet transfusion coagulation
profile should be done to rule out the cause of bleeding.
The DHS guidelines stipulate that platelet transfusion should be
given to patients with platelet count<20,000/cumm. In our study, 47
of the 97 patients receiving platelet transfusion followed the norms
laid down by DHS for the hospitalized dengue patients. 49 patients
had a platelet count greater than 20,000/cumm, 18 out of whom had
hemorrhagic manifestations like petechiae, gum bleeding, epistaxis,
etc. that necessitated the use of platelet transfusion. However, 31
(13.77%) patients received inappropriate platelet transfusion.
Kumar et al. had found 56.2% of inappropriate platelet transfusion
during dengue epidemics in Delhi during 1999. Many times the
prescription for this blood component are not based on medical
rationale, but as a response to an intense social pressure on the
treating physicians by the patients and their relatives
All the patients of DSS required platelet support. Two patients in age
group of 31-40 y were not given platelets as they died soon after
admission. None of the DHF patients<20 y required platelets. The
transfusion of platelets in DF was more in patients above the age of
11 than below 11 y as the possibility of repeat infections was higher.
Dengue patients can be categorized into the four categories based on
their platelet count at the time of admission:
1. High risk
2. Moderate risk
3. Low risk
4. No risk
High risk patient
The patients belonging to this group have platelet count
<20,000/cumm and they are at high risk of bleeding. Such patients
by the rule of the thumb should be receiving prophylactic platelet
transfusion. The patients in this category whose platelet count is less
than 10,000/cumm have even a greater risk and need to be
prioritized in case of an epidemic or, in case of limited resources.
Moderate risk
All the patients whose platelet count is in between 21-40,000/cumm
belong to moderate risk category. The patients of this risk group
should be transfused with platelet only if they have any
haemorrhagic symptoms.
Low risk
Those patients whose platelet count>40,000/cumm
but<100,000/cumm for the age and sex should be observed and
monitored carefully but should not receive unnecessary platelet
transfusion because of the risk of transmission of blood borne
infection (with no benefit of platelet transfusion).
No risk category
Patients falling in this category usually have the platelet
count>100,000/cumm. They should never be transfused with
platelet and should be managed on intravenous fluids and
supportive therapy.
CONCLUSION
All hospitalized dengue patients can be categorized into the high,
moderate, low and no risk patients based on their platelet count at
V. A. V. & A. Sharma
Int J Curr Pharm Res, Vol 15, Issue 4, 40-42
42
the time of hospitalization. The high-risk patients should be given
priority and the treating physician should take decision for platelet
transfusion. Moderate risk patients should be observed carefully and
platelet is transfused only if they have any haemorrhagic
manifestations. Low risk patients should not be given platelet
transfusion and should be managed on intravenous fluids and
supportive therapy.
FUNDING
Nil
AUTHORS CONTRIBUTIONS
All the authors have contributed equally.
CONFLICT OF INTERESTS
Declared none
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