At what platelet count is platelet transfusion indicated in patients with severe Dengue?

Platelet Transfusion Guidelines for Severe Dengue

Prophylactic platelet transfusions are not recommended in dengue patients with thrombocytopenia in the absence of active bleeding, regardless of platelet count. 1

Indications for Platelet Transfusion in Dengue

Active Bleeding

• Transfuse platelets to maintain count ≥50,000/μL in patients with active bleeding 2, 3
• For severe bleeding or patients requiring invasive procedures, maintain platelet count >100,000/μL 2
• Clinical bleeding, not platelet count alone, should guide transfusion decisions 1, 4

Prophylactic Transfusion

• Prophylactic platelet transfusion in dengue patients without bleeding does not reduce bleeding risk and may be harmful 1, 5
• A randomized controlled trial showed no significant difference in bleeding outcomes between transfused and non-transfused dengue patients with counts ≤20,000/μL (21% vs 26%, p=0.16) 1
• Potential harms of prophylactic transfusion include:
  • Delayed platelet recovery 5, 6
  • Increased length of hospitalization 5
  • Risk of transfusion reactions 1
  • Possible increased bleeding risk in patients with poor platelet recovery 6

Risk Stratification Approach

High-Risk Situations (Consider Platelet Transfusion)

• Active bleeding with platelet count <50,000/μL 2, 3
• Need for emergency surgery or invasive procedures 2, 4
• Severe bleeding with platelet count <100,000/μL, especially with:
  • Multiple traumatic injuries 2
  • Intracranial hemorrhage 2
  • Major surgical bleeding 2

Special Considerations

• Patients with poor platelet recovery (platelets remaining ≤20,000/μL after 2 days) may have worse outcomes if given prophylactic transfusions 6
• Risk factors for poor platelet recovery include:
  • Older age 6
  • Earlier presentation 6
  • Lower white cell count 6

Monitoring and Management Algorithm

1. Assess for active bleeding beyond petechiae

   • If present: Transfuse platelets to maintain count ≥50,000/μL 2, 3
   • If absent: Avoid prophylactic transfusion regardless of platelet count 1, 5

2. For patients requiring invasive procedures:

   • Major surgery: Maintain platelets >50,000/μL 2
   • Neurosurgery: Maintain platelets >100,000/μL 2
   • Central venous catheter insertion: Maintain platelets >20,000/μL 2

3. Monitor for warning signs of severe dengue requiring closer observation:

   • Rapid fall in platelet count 2
   • High fever 2
   • Development of coagulopathy 2

Common Pitfalls to Avoid

• Transfusing platelets based solely on platelet count without considering clinical bleeding status 1, 4, 7
• Unnecessary prophylactic transfusions that may delay recovery and prolong hospitalization 5
• Failure to recognize that serious hemorrhage in dengue can occur even at relatively normal platelet counts due to other factors affecting coagulation 2
• Inappropriate platelet transfusions in patients with platelet counts >20,000/μL without bleeding (36.62% of transfusions in one study were deemed inappropriate) 7

The evidence clearly demonstrates that prophylactic platelet transfusion in dengue patients with thrombocytopenia does not prevent bleeding and may be associated with adverse outcomes. Clinical decision-making should focus on the presence of active bleeding rather than arbitrary platelet count thresholds.