(All the articles published in past are available at www.shyamhemoncclinic.com)
Question: Dr. Chiragbhai, thank you for explaining in last part about approach to thrombocytopenia. I like the CATT approach, and your grading of thrombocytopenia, which make it much easier to conceptualize how to approach such a wide issue.
Ans: Thank you. Next step is ruling out serious potentially quickly fatal diagnoses. These diagnoses are likely to be missed in a busy practice, especially during a malaria or dengue season. Remember:
Acute leukemia, Sepsis, TTP-thrombotic thrombocytopenic purpura, HITT – heparin induced thrombocytopenia with thrombosis.
Some of these can be suspected clinically. It is important to communicate with pathologist if you are suspecting this, on laboratory order form or verbally. It is not a common practice in India yet, to communicate with pathologist or radiologist about clinical suspicion. This is very important, and can make a huge difference in arriving at right diagnosis in a timely manner. Every year we see at least one or two leukemia, initially labeled as dengue with low platelets. And we do see occasional mortality as well from these late diagnosed leukemias.
Many of the diagnoses that lead to thrombocytopenia can be diagnosed or suspected by good use of microscope. A good pathologist who spends time on microscope can mostly suspect acute leukemia, myelodysplastic syndrome, myeloproliferative disorders or other marrow infiltrative disorders and result in timely referral. He/she does not need to make a final diagnosis, just know when to call “abnormal or atypical cells”. And I know several such good pathologists even in small towns. Many hemato-oncological diseases, Malaria, TTP, infectious mononucleosis, hemoglobinopathies, various hemolytic anemias, iron or B12 deficiency and many others can be diagnosed/suspected by expert users of microscope.
Que: One very common and controversial issue is when to transfuse platelets and what type?
Ans: Yes. This is an important issue, and there is actually hardly any controversy, but more fear and reflex action practice, leading to many unnecessary transfusions. Patients and doctors do not realize the seriousness of blood transfusions. Since we do not have 100% voluntary blood donation i.e. many “replacement donations”, our blood supply pool is not as safe as in western world. Biggest safety comes from 100% voluntary donations coupled with high quality tests. We have concerns on both these fronts in India. This increases risk of transmitting hepatitis and HIV.
Hence any blood product should be transfused only when mandatory. There are other short term and long term risks of transfusions as well.
Platelet transfusion is rarely indicated in a patient with DENGUE. Most patients without bleeding can be observed even with platelet count of 10,000. Petechiae i.e. skin bleeding manifestations are not indication for platelet transfusion. For most other common diseases in a non hematologist/oncologist practice, platelet count above 20,000 rarely require platelet transfusion. It is painful to see many patients being transfused platelets above this count. In fact, every blood product should have a label stating “DANGEROUS MEDICINE, USE WITH EXTREME CAUTION”. Many large hospitals now require patient consent for any blood product transfusion, which underscores importance of reducing unnecessary transfusions.
One other question commonly asked is whether to transfuse SDP (single donor platelet) or RDP (random donor platelets). Both have same efficacy in increasing platelet count, given in right dose, in most cases. One SDP is equivalent of about 6-8 RDPs. For non hematologist practice, there is hardly any reason to prefer one over other. SDP takes time to prepare, needs a donor with same blood group, and is more expensive. It is useful when RDPs are not easily available, and to reduce number of donor exposure.
February 12th 2014.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com