Platelet Transfusion in Critical Care and Surgery

Abstract

Thrombocytopenia is prevalent in critical care, surgical, and trauma settings. Despite the fact that a significant proportion of these patients receive platelet transfusion during their hospital course, much work remains to be done with regard to development of platelet transfusion guidelines. Given the wide variety of platelet transfusion practices and the frequency with which patients present with thrombocytopenia, it is paramount to understand standards of care and to identify deficiencies that may exist. This review explores evidence and recommendations for platelet transfusion thresholds and practices in a variety of critical care and surgical settings with specific focus on the role of platelet transfusion in trauma, management and reversal of anticoagulation, and point of care laboratory assays. To this end, a literature review was performed utilizing PubMed and Cochrane Central Register of Controlled Trials to select 153 manuscripts that evaluate the current data supporting platelet transfusions in surgical and critical care populations. Advances in transfusion medicine and synthetic platelet substitutes that can be engineered for potential future applications will also be discussed.

Intravenous administration of synthetic platelets (SynthoPlate) in a mouse liver injury model of uncontrolled hemorrhage improves hemostasis

“…The lipid vesicle fabrication technique of ‘film rehydration and extrusion’ was used to manufacture SynthoPlate ™ as described previously. 13,14 Heteromultivalently decorated SynthoPlate ™ vesicles were produced and dynamic light scattering (DLS) and electron microscopy characterization indicated fresh-made vesicles were ~200nm in diameter as we have previously reported. 17…”

“…Given these challenges associated with platelet transfusions, there is significant clinical interest in extending the shelf-life and hemostatic viability of platelets via cold-storage and lyophilization 12,13 , as well as, in developing transfusable synthetic platelet substitutes that allow long-term storage and platelet-mimetic hemostatic action. 10,14,15 To this end, we have developed a synthetic platelet nanotechnology, namely SynthoPlate ™ , that incorporates the pro-adhesive and pro-aggregatory properties of native platelets by virtue of decorating a combination of platelet function-mimicking peptides (vWF-binding peptides or VBP, collagen binding peptides or CBP and active platelet GPIIb-IIIa-binding fibrinogen-mimetic peptides or FMP) on a biocompatible lipid vesicle platform.…”

Platelet-derived- Extracellular Vesicles Promote Hemostasis and Prevent the Development of Hemorrhagic Shock

“…While the use of PLTs in uncontrolled bleeding raised high expectations in clinical settings, the use of platelet-derived extracellular vesicles (PEVs), a heterogeneous pool of vesicles released from PLTs, may have many advantages over the cell-based approach 13,14 . Short shelf life, reduction in cell function over time, and in some cases, occurrence of transfusion-related acute lung injury are some of the major limitations in the use of PLTs 15–18 . PEVs share many functional features with PLTs such as high procoagulant capacity 19 , but could provide an alternative to PLTs for transfusion given their stability following freeze-thaw cycles 20 .…”

Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding

“…Activated platelets also secrete several granule contents, e.g., PolyP and vWF that can modulate and amplify various aspects of coagulation. Because of such multifactor role of platelets in clot promotion, transfusion of platelet concentrates (PC) has become an important clinical component in the prophylactic management of bleeding risks, as well as, emergency treatment of traumatic hemorrhage . However, the PC products at room temperature pose high risks of bacterial contamination, and also are known to undergo activation and degranulation during transport and storage, resulting in very short shelf‐life (3–5 d) .…”

“…To this end, for externally visible and accessible (often compressible) injuries, a variety of biomaterial‐based technologies in the form of powders, bandages, sprays, foams, gels, tourniquets, and tamponades have been developed . In contrast, for management of internal (often noncompressible) bleeding, the clinical gold standard is the transfusion of whole blood or blood components (RBC, plasma, and platelets), and use of fibrinogen concentrate or recombinant coagulation factors in selected groups of patients (e.g., recombinant Factor VIIa used in hemophilia patients) . However, donor‐derived blood and its components often have limited availability, require meticulous type matching, pose issues of high pathologic contamination or immunogenic risks, and have limited portability and short shelf‐life.…”