What are the indications for platelet (platelet concentrate) transfusion in patients with dengue?

Indications for Platelet Concentrate Transfusion in Dengue

In patients with dengue, platelet transfusion is NOT recommended prophylactically based on platelet count alone, but should be reserved for cases with active significant bleeding or patients requiring invasive procedures. 1

General Principles for Platelet Transfusion in Dengue

• Prophylactic platelet transfusion in dengue patients without bleeding does not reduce the risk of bleeding and may be associated with adverse events including transfusion reactions 2
• Prophylactic platelet transfusion in dengue patients without bleeding may actually slow platelet recovery and increase hospital length of stay 3
• In patients with consumptive thrombocytopenia due to dengue without major bleeding, platelet transfusion is not recommended regardless of platelet count 1

Specific Indications for Platelet Transfusion in Dengue

Active Bleeding

• Platelet transfusion is indicated for patients with severe bleeding regardless of platelet count 4
• The goal should be to maintain platelet count above 50 × 10^9/L in patients with active significant bleeding 5

Invasive Procedures

• For patients requiring invasive procedures:
  • Central venous catheter placement: transfuse if platelet count is less than 20 × 10^9/L 5
  • Lumbar puncture: transfuse if platelet count is less than 50 × 10^9/L 5
  • Major surgery: transfuse to maintain platelet count above 50 × 10^9/L 5, 6

High-Risk Patients

• Consider platelet transfusion in patients with platelet counts below 20 × 10^9/L with additional risk factors for bleeding such as:
  • Concomitant coagulopathy 5
  • Severe hypertension 4
  • Recent use of antiplatelet or anticoagulant medications 4

Dosing and Administration

• When platelet transfusion is indicated, an initial dose of 4-8 platelet concentrates or one apheresis pack is suggested 5, 6
• Always obtain a post-transfusion platelet count to confirm adequate increment 5
• The median platelet yield is approximately +12.4% after transfusion in dengue patients 4

Potential Harms of Inappropriate Platelet Transfusion

• Randomized controlled trials have shown that prophylactic platelet transfusion in dengue is not superior to supportive care in preventing bleeding 2
• Potential adverse events associated with platelet transfusion include:
  • Urticaria, rash, and pruritus 2
  • Anaphylaxis 2
  • Transfusion-related acute lung injury 2
  • Fluid overload 2
• Patients with poor platelet recovery were more likely to bleed if given prophylactic platelet transfusion (odds ratio 2.34) 7

Practical Approach

• Focus on careful clinical monitoring and supportive care rather than prophylactic platelet transfusion 2
• Maintain adequate hydration and monitor for signs of plasma leakage 4
• Reserve platelet transfusion for patients with:
  • Active significant bleeding 4
  • Platelet count <20 × 10^9/L with high-risk invasive procedures 5
  • Platelet count <50 × 10^9/L with lumbar puncture or major surgery 5

Monitoring After Transfusion

• Monitor for clinical response and resolution of bleeding 4
• Assess for transfusion-related adverse events 2
• Repeat platelet count to evaluate increment 5
• Be prepared to provide additional transfusions if clinically indicated 5