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An Octogenarian Patient Of Intracapsular
Neck Of Femur Fracture With Pre-operative
Big Challenge Thrombocytopenia
Presenter- Dr. Shiny
PG JR 2nd Year
Dept. Of Immunohematology & Blood Transfusion
Requisition on 24/01/2024
• We received a requisition for 2 units of single Donor
Platelets for an 81 years old Male patient, at 4.20 pm.
• Indication- Pre-operative Thrombocytopenia
• Pre-transfusion platelet count- 40,000/uL
ABO-Rh typing
ABO-Rh typing- O positive
Collection and Preparation
Donor selection and
screening
Time taken
for procedure
Yield Volume Quality control
SDP 1 Family was unable to
arrange donor, so,
donors were requested
by local NGOs
Pre-collection screening
was done including
CBC and TTI screening
of the donors.
67 minutes 4.0 x 1011 286 ml Platelets- 14,90,000/uL
WBC- 0.00/uL
RBC- 0.01/uL
TTI tested by Chemiluminescence
SDP 2 76 minutes 4.0 x 1011 294 ml Platelets- 13,38,000/uL
WBC- 0.00
RBC- 0.00
TTI tested by Chemiluminescence
Transfusion
• Both SDP products were requested together
• Issued on 26/01/2024 at 3.45 am
• SDP 1- Transfused on 26/01/2024 at 4 am.
• SDP 2- Transfused on 26/01/2024 at 5 am.
• TTI tested by Chemiluminescence
• ABO compatible
• No Transfusion reaction was reported on both transfusions.
PRBC Transfusion
1st PRBC Transfusion
27/01/2024
2nd PRBC transfusion
01/02/2024
Indication- Hb 8.5 gm/dl
370 mL O positive PRBC at 5.55 pm
DOC- 14/01/2024
PTT- Compatible
No transfusion reaction reported
Indication- Hb 6.9 gm/dl
380 mL O positive PRBC at 10.46 pm
DOC- 15/01/2024
PTT- Compatible
No transfusion reaction reported
Follow up at Blood Centre
Antiglobulin tests- Negative
Antibody screening- Negative
Platelet count, Hb, INR trends
Pre-
transfusion
24/01/2024
1 hour
increment Post
2 SDP
transfusions
26/01/2024
24 hours
increment
27/01/2024
After 1st
PRBC
Transfusion
28/01/2024 29/01/24 to 01/02/24
After 2nd
PRBC
Transfusion
02/02/2024
Platelet count
(per uL)
Hb (gm/dl)
40000
9.3
1,64,000
8.0
1,60,000
8.5
1,23,000
9.6
1,05,000 to 89000 to
71000 to 55000
8.8 to 8.1 to 7.5 to 6.9
50,000 to
75,000
8.0 to 8.2
Increment- 62000/uL per SDP unit transfusion
1 gm/dl per PRBC transfusion
So, not a case of transfusion refractoriness
Apheresis
• In apheresis, blood is withdrawn from a donor in an
anticoagulant solution and separated into
components. One (or more) component is/are
retained, and the remaining constituents are returned
to the donor.
• In a plateletpheresis procedure, donor’s platelet are
removed from whole blood, and the remaining
components are returned back to the donor.
Principle
• The anticoagulated blood from the donor is pumped into a rotating bowl, separating
the incoming blood by centrifugal force in such a way that red cells move to
periphery and plasma to the inside of rotating bowl and white cells and
platelets layer between the red cells and plasma.
• A portion of the donor’s platelets and some plasma is removed with the return of the
donor’s RBCs, WBCs, and remaining plasma.
• A plateletpheresis procedure usually takes 6-8 cycles to collect a therapeutic dose.
Routine procedure takes 1-1.5 hours.
Storage- 5 days on platelet agitator at 22
degrees.(the day of collection of platelets-
day zero)
Donation Criteria
1. Donor weight >50 Kg, Age- 18 to 60 years
2. The interval between procedures should be at least 48 hours. A donor should not
undergo the procedure more than 2 times a week or 24 times a year. After the whole
blood donation, the donor should be accepted only after 28 days of interval.
3. Platelet count and Hb must be more than 150,000/μl and > 12.5 g/dl before starting
the procedure.
4. Double unit apheresis can be taken in donors whose platelet count is more than
250,000/ul and weight more than 60kg and those who are not 1st time apheresis donors.
SDP vs RDP
SDP RDP
Collection obtained from an apheresis donation Platelets derived from whole blood
the platelet product
Volume 50-70 mL >200 mL
Yield and Increment one SDP unit, containing a minimum
of 3x1011 platelets, should increase an
adult’s platelets by 30,000 to
70,000/μL
one RDP unit, containing at least
5.5x1010 platelets, should increase
platelet count by 5,000 to 10,000/μL.
Advantages • More platelet increment
• Safer
• Leucoreduced
• Cost effective
• ABO incompatible units can be
transfused
Disadvantages • Expensive
• Same blood group apheresis donor
required for preparation
• 5-6 folds higher risk of bacterial
contamination
• 2 folds higher risk of TTIs as
compared to SDPs
Age Age-specific in older adults include enhanced platelet
aggregation and increased fibrinogen, factor V, and von
Willebrand factor to maintain normal hemostasis in age-related
changed organ and vasculature systems- chronic medications,
Loss of subcutaneous tissue
Splenomegaly causes platelets to pool inside of the spleen and cause
thrombocytopenia (low platelets available in peripheral blood).
Chronic
disorders
(HTN,
NSTEMI)
Decreasing platelet counts trend may be a consequence of
platelet hyperdestruction secondary to abnormal platelet
activation in a deteriorating disease state. In addition, the
severity of thrombocytopaenia may be a marker of more severe
right heart failure and abnormal haemodynamics.
References
• McMahon BJ, Kwaan HC. Thrombocytopenia in older adults. Seminars in thrombosis and hemostasis.
2014;40(6):682-687. 2. Aster RH, Curtis BR, McFarland JG, Bougie DW.
• Drug-induced immune thrombocytopenia: pathogenesis, diagnosis, and management. Journal of thrombosis and
haemostasis : JTH. 2009;7(6):911-918.
• https://www.ncbi.nlm.nih.gov/books/NBK537240/#:~:text=Immune%20thrombocytopenic%20purpura%20(ITP)%
20is%20an%20autoimmune%20disease%20characterized%20by,autoantibodies%20sensitize%20the%20circulatin
g%20platelets.
• Principles and Practice of Transfusion Medicine, Dr. R. N. Makroo, 2nd edition
• Harmening DM. Modern Blood Banking & Transfusion Practices 7th edition

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An Octogenarian Patient Of Intracapsular Neck Of Femur Fracture With Pre-operative Big Challenge Thrombocytopenia

  • 1. An Octogenarian Patient Of Intracapsular Neck Of Femur Fracture With Pre-operative Big Challenge Thrombocytopenia Presenter- Dr. Shiny PG JR 2nd Year Dept. Of Immunohematology & Blood Transfusion
  • 2. Requisition on 24/01/2024 • We received a requisition for 2 units of single Donor Platelets for an 81 years old Male patient, at 4.20 pm. • Indication- Pre-operative Thrombocytopenia • Pre-transfusion platelet count- 40,000/uL
  • 4. Collection and Preparation Donor selection and screening Time taken for procedure Yield Volume Quality control SDP 1 Family was unable to arrange donor, so, donors were requested by local NGOs Pre-collection screening was done including CBC and TTI screening of the donors. 67 minutes 4.0 x 1011 286 ml Platelets- 14,90,000/uL WBC- 0.00/uL RBC- 0.01/uL TTI tested by Chemiluminescence SDP 2 76 minutes 4.0 x 1011 294 ml Platelets- 13,38,000/uL WBC- 0.00 RBC- 0.00 TTI tested by Chemiluminescence
  • 5.
  • 6. Transfusion • Both SDP products were requested together • Issued on 26/01/2024 at 3.45 am • SDP 1- Transfused on 26/01/2024 at 4 am. • SDP 2- Transfused on 26/01/2024 at 5 am. • TTI tested by Chemiluminescence • ABO compatible • No Transfusion reaction was reported on both transfusions.
  • 7. PRBC Transfusion 1st PRBC Transfusion 27/01/2024 2nd PRBC transfusion 01/02/2024 Indication- Hb 8.5 gm/dl 370 mL O positive PRBC at 5.55 pm DOC- 14/01/2024 PTT- Compatible No transfusion reaction reported Indication- Hb 6.9 gm/dl 380 mL O positive PRBC at 10.46 pm DOC- 15/01/2024 PTT- Compatible No transfusion reaction reported
  • 8. Follow up at Blood Centre Antiglobulin tests- Negative Antibody screening- Negative
  • 9. Platelet count, Hb, INR trends Pre- transfusion 24/01/2024 1 hour increment Post 2 SDP transfusions 26/01/2024 24 hours increment 27/01/2024 After 1st PRBC Transfusion 28/01/2024 29/01/24 to 01/02/24 After 2nd PRBC Transfusion 02/02/2024 Platelet count (per uL) Hb (gm/dl) 40000 9.3 1,64,000 8.0 1,60,000 8.5 1,23,000 9.6 1,05,000 to 89000 to 71000 to 55000 8.8 to 8.1 to 7.5 to 6.9 50,000 to 75,000 8.0 to 8.2 Increment- 62000/uL per SDP unit transfusion 1 gm/dl per PRBC transfusion So, not a case of transfusion refractoriness
  • 10. Apheresis • In apheresis, blood is withdrawn from a donor in an anticoagulant solution and separated into components. One (or more) component is/are retained, and the remaining constituents are returned to the donor. • In a plateletpheresis procedure, donor’s platelet are removed from whole blood, and the remaining components are returned back to the donor.
  • 11. Principle • The anticoagulated blood from the donor is pumped into a rotating bowl, separating the incoming blood by centrifugal force in such a way that red cells move to periphery and plasma to the inside of rotating bowl and white cells and platelets layer between the red cells and plasma. • A portion of the donor’s platelets and some plasma is removed with the return of the donor’s RBCs, WBCs, and remaining plasma. • A plateletpheresis procedure usually takes 6-8 cycles to collect a therapeutic dose.
  • 12. Routine procedure takes 1-1.5 hours. Storage- 5 days on platelet agitator at 22 degrees.(the day of collection of platelets- day zero)
  • 13. Donation Criteria 1. Donor weight >50 Kg, Age- 18 to 60 years 2. The interval between procedures should be at least 48 hours. A donor should not undergo the procedure more than 2 times a week or 24 times a year. After the whole blood donation, the donor should be accepted only after 28 days of interval. 3. Platelet count and Hb must be more than 150,000/μl and > 12.5 g/dl before starting the procedure. 4. Double unit apheresis can be taken in donors whose platelet count is more than 250,000/ul and weight more than 60kg and those who are not 1st time apheresis donors.
  • 14. SDP vs RDP SDP RDP Collection obtained from an apheresis donation Platelets derived from whole blood the platelet product Volume 50-70 mL >200 mL Yield and Increment one SDP unit, containing a minimum of 3x1011 platelets, should increase an adult’s platelets by 30,000 to 70,000/μL one RDP unit, containing at least 5.5x1010 platelets, should increase platelet count by 5,000 to 10,000/μL. Advantages • More platelet increment • Safer • Leucoreduced • Cost effective • ABO incompatible units can be transfused Disadvantages • Expensive • Same blood group apheresis donor required for preparation • 5-6 folds higher risk of bacterial contamination • 2 folds higher risk of TTIs as compared to SDPs
  • 15.
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  • 18. Age Age-specific in older adults include enhanced platelet aggregation and increased fibrinogen, factor V, and von Willebrand factor to maintain normal hemostasis in age-related changed organ and vasculature systems- chronic medications, Loss of subcutaneous tissue Splenomegaly causes platelets to pool inside of the spleen and cause thrombocytopenia (low platelets available in peripheral blood). Chronic disorders (HTN, NSTEMI) Decreasing platelet counts trend may be a consequence of platelet hyperdestruction secondary to abnormal platelet activation in a deteriorating disease state. In addition, the severity of thrombocytopaenia may be a marker of more severe right heart failure and abnormal haemodynamics.
  • 19.
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  • 21. References • McMahon BJ, Kwaan HC. Thrombocytopenia in older adults. Seminars in thrombosis and hemostasis. 2014;40(6):682-687. 2. Aster RH, Curtis BR, McFarland JG, Bougie DW. • Drug-induced immune thrombocytopenia: pathogenesis, diagnosis, and management. Journal of thrombosis and haemostasis : JTH. 2009;7(6):911-918. • https://www.ncbi.nlm.nih.gov/books/NBK537240/#:~:text=Immune%20thrombocytopenic%20purpura%20(ITP)% 20is%20an%20autoimmune%20disease%20characterized%20by,autoantibodies%20sensitize%20the%20circulatin g%20platelets. • Principles and Practice of Transfusion Medicine, Dr. R. N. Makroo, 2nd edition • Harmening DM. Modern Blood Banking & Transfusion Practices 7th edition