What are the signs of active bleeding in a dengue patient that require platelet transfusion?

Signs of Active Bleeding in Dengue Patients Requiring Platelet Transfusion

Platelet transfusion in dengue patients should only be administered when there is active significant bleeding, not prophylactically based on platelet count alone. 1

Clinical Signs of Active Bleeding Requiring Platelet Transfusion

Active bleeding in dengue patients that may warrant platelet transfusion includes:

• Severe or major hemorrhage defined by:

  • Externalized bleeding that cannot be controlled by usual means 2
  • Hemodynamic instability (systolic BP <90 mmHg or 40 mmHg lower than usual, mean arterial pressure <65 mmHg, or signs of shock) 2
  • Need for urgent hemostatic procedures (surgery, interventional radiology, endoscopy) 2
  • Need for red blood cell transfusion 2

• Bleeding at critical locations that threaten vital or functional prognosis:

  • Intracranial or intraspinal hemorrhage 2
  • Intraocular or retroocular hemorrhage 2
  • Hemothorax, hemoretroperitoneum, hemopericardium 2
  • Deep muscular hematoma or compartment syndrome 2
  • Acute gastrointestinal bleeding 2, 3
  • Hemarthrosis 2

Common Bleeding Sites in Dengue

• Skin and oropharynx are the most common bleeding sites in dengue patients 4
• Major bleeding occurs in approximately 34.3% of dengue patients with bleeding diathesis 4

Transfusion Guidance

• Platelet transfusion should be considered when active bleeding persists after failure of etiological and symptomatic treatments 2
• Non-severe hemorrhages require only symptomatic treatment without platelet transfusion 2
• Prophylactic platelet transfusion in dengue patients with thrombocytopenia but without active bleeding is not recommended as it has not been shown to prevent bleeding and may be associated with adverse events 1

Important Clinical Considerations

• Poor platelet recovery (platelets remaining ≤20,000/μL after 2 days) is associated with:

  • Older age
  • Lower white cell count
  • Earlier presentation in illness course 5

• Patients with poor platelet recovery who receive prophylactic platelet transfusion may actually have an increased risk of bleeding (OR 2.34,95% CI 1.18-4.63) 5

• Transfusion-related adverse events can occur in up to 5.8% of dengue patients receiving platelet transfusions, including:

  • Urticaria, rash, pruritus
  • Anaphylaxis
  • Transfusion-related acute lung injury
  • Fluid overload 1

Monitoring Parameters

• Regular assessment of vital signs to detect hemodynamic instability 2
• Serial platelet counts to monitor response to transfusion 5
• Careful evaluation for signs of plasma leakage and cardiopulmonary dysfunction, which correlate with unfavorable outcomes 3

Special Populations

• For patients on long-term antiplatelet therapy who develop dengue with thrombocytopenia:
  • Clinical judgment regarding continuation or discontinuation of antiplatelet therapy appears to be safe 6
  • Neither continuation nor discontinuation of antiplatelet therapy has been associated with increased need for platelet transfusion or higher rates of dengue hemorrhagic fever 6

Remember that clinical judgment remains important, as the evidence suggests that transfusion should be reserved for cases with clinically significant active bleeding rather than based solely on platelet count thresholds.