Management of Severe Thrombocytopenia in Dengue Fever
Platelet transfusion is indicated for this dengue fever patient with severe thrombocytopenia (18,000/μL) and warning signs (50% drop in platelets within 24 hours). This rapid drop in platelets represents a significant risk factor for bleeding complications and requires immediate intervention.
Assessment and Initial Management
- Evaluate for active bleeding manifestations (petechiae, gum bleeding, melena, etc.)
- Check TEG parameters (elevated r, k and low alpha angle and MA) indicate coagulopathy
- Monitor vital signs for signs of shock or plasma leakage
Platelet Transfusion Protocol
Indications for Transfusion:
- Platelet count below 20,000/μL in dengue fever with warning signs 1
- Presence of significant bleeding or high risk of bleeding 2
Dosing Recommendations:
- Initial dose: 4-8 platelet concentrates or one apheresis pack 2
- Expected increment: Approximately 30 × 10^9/L per adult dose 2
- Target platelet count: Maintain above 50 × 10^9/L in patients with ongoing bleeding 2
Administration Guidelines:
- Infuse over 30 minutes through a standard blood administration set with 170-200 μm filter 2
- Do not use a set previously used for red cells 2
- Begin transfusion within 30 minutes of removal from storage 2
Monitoring After Transfusion
- Repeat platelet count 1 hour post-transfusion to assess response
- Monitor clinical bleeding status
- Be aware that survival of transfused platelets may be very short in dengue (few hours to one day) due to:
- Platelet adhesion to injured vessels
- Immune complex reactions
- Rapid utilization and destruction by injured vessels 3
Additional Management Considerations
Fresh Frozen Plasma:
- Consider FFP (15-30 mL/kg) if there is active bleeding with coagulopathy 2
- May provide temporary improvement in platelet counts in the first 12 hours 4
Fibrinogen Replacement:
- If fibrinogen levels are below 1.5 g/L with active bleeding, consider:
- Cryoprecipitate (two pools) or
- Fibrinogen concentrate (3-4g) 2
Supportive Care:
- Maintain adequate hydration while avoiding fluid overload
- Monitor for signs of plasma leakage or shock
- Avoid medications that may impair platelet function (NSAIDs, etc.)
Important Caveats
- Bleeding manifestations in dengue don't always correlate with platelet count 1
- The degree of elevation of circulating platelets after transfusion varies inversely with the degree of shock 3
- Unnecessary and empirical use of platelets should be avoided, especially during epidemics when there is scarcity 1
- Transfused platelets may have very short survival in dengue patients with shock 3
This patient's rapid drop in platelet count to 18,000/μL with TEG evidence of coagulopathy represents a clear indication for platelet transfusion according to current guidelines, with the goal of preventing serious hemorrhagic complications.