Thrombocytopenia resident survival guide
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Abruptio placentae
- Bone marrow suppression (chemotherapy, irradiation)
- Cardica bypass
- Chronic alcohol use
- Chronic liver disease
- Common variable immunodeficiency
- Congenital thrombocytopenia
- Connective tissue disorders (eg SLE, RA, antiphospholipid syndrome)
- Disseminated intravascular coagulation
- GP IIb/IIIa inhibitor
- Hemolytic uremic syndrome
- Heparin-induced thrombocytopenia
- Immune thrombocytopenic purpura
- Macrophage-activation syndrome
- Thrombotic thrombocytopenic purpura
Shown below is an algorithm depicting the initial approach to thrombocytopenia.
Characterize the symptoms:
❑ Onset (acute, chronic, recurrent)
❑ Easy bruising
❑ Abdominal pain
❑ Visual disturbances
❑ Weight loss
❑ Night sweats
❑ Bone pain
Obtain a detailed history:
❑ Recent medications
❑ Family history
❑ Recent infection
❑ Recent vaccinations
❑ Recent travels
❑ Recent transfusions
❑ Chronic alcohol use
❑ Recent hospitalization
❑ Recent organ transplantation
❑ Recent valve replacement surgery
❑ Dietary habits
❑ Sexual history
❑ Ingestion of quinine containing beverages
|❑ Order additional tests based on the results of the CBC-D and peripheral blood smear|
❑ Clumped platelets
|❑ Order platelet count on heparinized blood specimen||Isolated thrombocytopenia||Thrombocytopenia with abnormalities in other blood lineages|
|Guide your next step by specific findings|
|Consider: ||Look for:|
Note that the treatment of thrombocytopenia is specific to the underlying cause of thrombocytopenia.
Shown below is a table summarizing different findings on the peripheral blood smear findings and their associated conditions.
|Findings on the peripheral blood smear||Associated conditions|
|Giant platelets||Hereditary thrombocytopenia|
|Schistocytes||DIC, TTP, HUS|
|Blasts||Bone marrow disorder|
|Nucleated RBCs||Hemolytic anemia, myelofibrosis, infiltration of the bone marrow|
|Megaloblastic anemia e.g. vitamin B12 deficiency, folate deficiency|
|Leukemic cells||Hematological malignancies|
|Pancytopenia||Aplastic anemia, myelodysplastic syndrome, leukemia|
|Microspherocytes||Evans syndrome, thrombotic angiopathies|
|Macrocytosis||Vitamin B12 deficiency, folate deficiency|
Indications for Platelet Transfusion in Thrombocytopenia
- Consider platelet transfusion in the following conditions if the platelet count is less than:
- Bone marrow aspirations and biopsies can safely be performed at platelet counts <20,000/μL.
- Platelet transfusions in patients with chronic thrombocytopenia is usually indicated with a WHO bleeding grade of ≥ 2.
- For invasive procedures, it is recommended that a platelet count of at least 50,000/μL be maintained.
- The extent of surgery, ability to control bleeding, presence of platelet dysfunction and other coagulation defects determines when to make a decision to transfuse with a platelet count between 50,000 and 100,000/μL.
- Platelet transfusion to control or prevent bleeding with trauma or surgical procedures require higher transfusion thresholds of 100,000/μL for neurosurgical procedures.
- An acutely bleeding surgical patient usually requires platelet transfusion if the platelet count is < 50,000/μL and rarely if the count is > 100,000/μL.
- In acute DIC and with substantial bleeding, it is recommended to maintain the platelet count around 50,000/μL.
- In ITP, the transfusion of platelets is indicated in major and/or dangerous cases of hemorrhage (e.g. intracranial or intraocular hemorrhage).
- In acquired or congenital disorders of platelet function, platelet transfusion is indicated only in cases of perioperative hemorrhage.
WHO Bleeding Grades
|Grade 0||Grade 1 - Minor bleeding||Grade 2 - Mild bleeding||Grade 3 - Major bleeding||Grade 4 - Disabling bleeding|
Occult blood in body secretions
Mild vaginal spotting
|Evidence of gross hemorrhage not requiring red cell transfusion e.g. Epistaxis, hematuria, hematemesis||Hemorrhage requiring transfusion of 1 or more units of red cells/day||Life threatening hemorrhage e.g. Intracranial hemorrhage, pericardial hemorrhage, pulmonary hemorrhage|
- Order a peripheral blood smear in all patients with thrombocytopenia and check out the morphology of all blood cells lineages. The peripheral blood smear is one of the most important tests to order in the evaluation of thrombocytopenia.
- Consider the following diagnoses in the following categories of patients:
- Critically ill patients: leukemia, manifested by blasts, and thrombotic microangiopathy, characterized by the presence of schistocytes
- Hospitalized patients: HIT and DIC
- Cardiac surgery patients: mechanical destruction, hemodilution, drug induced thrombocytopenia
- Patients undergoing PCI: Drug induced thrombocytopenia (GpIIb-IIIa inhibitors)
- Pregnant women: Gestational thrombocytopenia, preeclampsia, ITP
- If drug induced thrombocytopenia is suspected, stop the possible offending drug.
- Consider isolated thrombocytopenia in patients with thrombocytopenia in the absence of any systemic symptoms and the absence of any abnormalities in the other blood cells lineages.
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