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

Indications for Platelet Transfusion in Dengue

Platelet transfusion in dengue patients is primarily indicated for active significant bleeding with a target platelet count of ≥50,000/mm³, and is not recommended prophylactically for thrombocytopenia alone without bleeding. 1, 2

Specific Indications Based on Clinical Presentation

Active Bleeding

• Transfuse platelets to maintain count ≥50,000/mm³ in patients with active significant bleeding 1, 2
• This recommendation aligns with guidelines from the American College of Critical Care Medicine 1

Invasive Procedures

• For central venous catheter placement: transfuse if platelet count is <20,000/mm³ 1, 2
• For lumbar puncture: transfuse if platelet count is <50,000/mm³ 1, 2
• For major surgery: maintain platelet count above 50,000/mm³ 2
• For minor procedures: thresholds vary from 20,000-50,000/mm³ depending on procedure type 1
• Always obtain post-transfusion platelet count to confirm adequate increment 2

Special Risk Factors

• Consider platelet transfusion in patients with platelet counts <20,000/mm³ with additional risk factors such as:
  • Concomitant coagulopathy 2
  • Advanced age, hypertension, peptic ulcer disease 1
  • Anticoagulant use, recent trauma or surgery 1

Evidence Against Prophylactic Transfusion

Recent high-quality evidence strongly discourages prophylactic platelet transfusion in dengue patients with thrombocytopenia but without bleeding:

• A randomized controlled trial demonstrated that prophylactic platelet transfusion was not superior to supportive care in preventing bleeding in adult dengue patients with thrombocytopenia 3
• Prophylactic transfusion may be associated with adverse events including urticaria, rash, pruritus, chest pain, anaphylaxis, transfusion-related acute lung injury, and fluid overload 3
• Patients receiving prophylactic platelet transfusion took longer to increase their platelet count to 50,000/mm³ (3 days vs. 2 days) compared to non-transfused patients 4
• Transfused patients had longer hospital stays (median 6 days vs. 5 days) 4
• In patients with poor platelet recovery, platelet transfusion may actually increase the risk of bleeding 5

Practical Approach to Platelet Transfusion in Dengue

1. Assess for active bleeding:

   • If present and significant, transfuse platelets to maintain count ≥50,000/mm³ 1, 2
   • Initial dose: 4-8 platelet concentrates or one apheresis pack 2

2. Evaluate need for invasive procedures:

   • Maintain platelets at appropriate threshold based on procedure type 1, 2
   • For major procedures: maintain platelets ≥50,000/mm³ 2
   • For minor procedures: thresholds vary from 20,000-50,000/mm³ 1

3. For patients without bleeding or need for procedures:

   • Avoid prophylactic platelet transfusion, even with very low counts 3, 4
   • Focus on supportive care including bed rest, fluid therapy, and fever/pain management 3

4. Monitor closely:

   • Observe for signs of bleeding
   • Monitor platelet count trends
   • Always check post-transfusion platelet count when transfusion is given 2

Common Pitfalls to Avoid

• Unnecessary prophylactic platelet transfusions in non-bleeding patients with thrombocytopenia 6
• Failure to obtain post-transfusion platelet counts to confirm adequate increment 2
• Overlooking potential adverse events associated with platelet transfusion 3
• Focusing solely on platelet count rather than clinical bleeding and overall patient status 7