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Quality of evidence-based guidelines for platelet transfusion and use: A systematic review
Al-Riyami AZ, Jug R, La Rocca U, Keshavarz H, Landry D, Shehata N, Stanworth SJ, Nahirniak S
Transfusion. 2021
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Editor's Choice
Abstract
BACKGROUND Guidelines for platelet (PLT) transfusion are an important source of information for clinicians. Although guidelines intend to increase consistency and quality of care, variation in methodology and recommendations may exist that could impact the value of a guideline. We aimed to determine the quality of existing PLT transfusion guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to describe the inconsistencies in recommendations. STUDY DESIGN AND METHODS A systematic search was undertaken for evidence-based guidelines from January 1, 2013, to January 25, 2019. Citations were reviewed in duplicate for inclusion and descriptive data extracted. Four physicians appraised the guideline using the AGREE II instrument and the scaled score for each item evaluated was calculated. The protocol was registered in PROSPERO. RESULTS Of 6744 citations, 6740 records were screened. Seven of 28 full-text studies met the inclusion criteria. The median scaled score (and the interquartile range of the scaled score) for the following items were as follows: scope and purpose, 94% (8%); stakeholder involvement, 63% (18%); rigor of development, 83% (14%); clarity of presentation, 94% (6%); applicability, 58% (20%); and editorial independence, 77% (4%). Overall quality ranged from 4 to 7 (7 is the maximum score). Inconsistent recommendations were on prophylactic PLT transfusion in hypoproliferative thrombocytopenia in the presence of risk factors and dose recommendations. CONCLUSION Inconsistencies between guidelines and variable quality highlight areas for future guideline writers to address. Areas of specific attention include issues of stakeholder involvement and applicability.
PICO Summary
Population
Guidelines for platelet (PLT) transfusion (7 studies).
Intervention
Systematic review to determine the quality of existing PLT transfusion guidelines and to describe the inconsistencies in recommendations.
Comparison
Outcome
The median scaled score for the following items were as follows: scope and purpose, 94%; stakeholder involvement, 63%; rigor of development, 83%; clarity of presentation, 94%; applicability, 58%; and editorial independence, 77%. Overall quality ranged from 4 to 7 (7 was the maximum score). Inconsistent recommendations were found on prophylactic PLT transfusion in hypoproliferative thrombocytopenia in the presence of risk factors, and dose recommendations.
2.
Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis
Kleinveld DJB, van Amstel RBE, Wirtz MR, Geeraedts LMG, Goslings JC, Hollmann MW, Juffermans NP
Transfusion. 2021;61 Suppl 1:S243-s251
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Free full text
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Editor's Choice
Abstract
BACKGROUND In traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet-to-red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet-to-RBC. METHODS Pubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30-day mortality, thromboembolic events, organ failure, and correction of coagulopathy. RESULTS In total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53-0.89]) and 30- day mortality (OR 0.78 [0.63-0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy. CONCLUSIONS In traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.
PICO Summary
Population
Bleeding trauma patients receiving platelet transfusion (5 studies, n= 1,757).
Intervention
Higher platelet-to-red blood cell (RBC) transfusion ratio.
Comparison
Lower ratio of platelet-to-RBC.
Outcome
A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio (OR) 0.69 (0.53-0.89)) and 30- day mortality (OR 0.78 (0.63-0.98)). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma-induced coagulopathy.
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The role of platelet transfusions after intracranial hemorrhage in patients on antiplatelet agents: a systematic review and meta-analysis
Brogi E, Corbella D, Coccolini F, Gamberini E, Russo E, Agnoletti V, Forfori F
World Neurosurg. 2020
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Full text
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Editor's Choice
Abstract
The current evidence suggests that Antiplatelet agents (APA) slightly increase the risk of death and disease progression in patients with traumatic (TBI) or spontaneous intracranial hemorrhage (ICH). Disappointingly there is little evidence that APA reversal with platelet transfusion (PLT) may improve the outcome. In this systematic review and meta-analysis, our goal was to evaluate the differences in mortality, severe disability, and hematoma expansion related to PLT transfusion. We retrieved randomized, or cohort studies comparing adult patients on APA with TBI or ICH who were treated with PLT or not. We calculated the standardized Risk Difference (RD) and 95% CI. A random-effects model was applied to analyze the data. The heterogeneity of the retrieved trials was evaluated through the I(2) statistic. Our review finally included 16 clinical trials. We observed a significant difference between the two groups only for hematoma expansion: RD was -0.10 (10%; 95% CI: -0.14 to -0.05; P<0.0001; I(2)=0.90) in favor of PLT transfusion. Performing subgroups analyses according to the type of bleeding mechanism, we observed the same results. The use of PLT in patients on APA affected by intracranial hemorrhage seemed to have no clear beneficial effect for the outcomes evaluated; conversely, PLT appeared to slightly increase the odds for adverse events of thromboembolic origin, even though not significantly.
PICO Summary
Population
Adult patients on antiplatelet agents (APA) with traumatic brain injury (TBI) or spontaneous intracranial hemorrhage (ICH), (16 clinical trials).
Intervention
Platelet transfusion (PLT).
Comparison
No platelet transfusion.
Outcome
A significant difference was observed between the two groups only for hematoma expansion: standardized risk difference was -0.10 in favor of PLT transfusion. The same results were observed when performing subgroups analyses according to the type of bleeding mechanism. The use of PLT in patients on APA affected by intracranial hemorrhage seemed to have no clear beneficial effect for the outcomes evaluated; conversely, PLT appeared to slightly increase the odds for adverse events of thromboembolic origin, even though not significantly.
4.
A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?
Alvikas J, Myers SP, Wessel CB, Okonkwo DO, Joseph B, Pelaez C, Doberstein C, Guillotte AR, Rosengart MR, Neal MD
The journal of trauma and acute care surgery. 2020
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Free full text
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Editor's Choice
Abstract
BACKGROUND Platelet transfusion has been utilized to reverse platelet dysfunction in patients on pre-injury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS Controlled, observational and randomized, prospective and retrospective studies describing tICH, pre-injury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS Twelve articles out of 18609 screened references were applicable to our PICOS questions were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (OR 1.29; 95% CI 0.76-2.18; p=0.346; I=32.5%). There was no significant reduction in hemorrhage progression (OR 0.88; 95% CI 0.34-2.28; p=0.788; I=78.1%). There was no significant reduction in the need for neurosurgical intervention (OR 1.00, 95% CI 0.53-1.90, p=0.996, I=59.1%, p=0.032). CONCLUSIONS Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE level III, Systematic Reviews and Meta-Analyses.
PICO Summary
Population
Patients with traumatic intracranial hemorrhage (tICH) on prehospital antiplatelet medication, (12 studies).
Intervention
Platelet transfusion to reverse platelet dysfunction.
Comparison
Outcome
No association was found between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (OR 1.29, I2= 32.5%). There was no significant reduction in hemorrhage progression (OR 0.88, I2= 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR 1.00, I2= 59.1%).