Critical platelet shortages and a single Institution's experience with split platelet transfusions: Can you get by with just half a unit? Free

Introduction Blood product shortages have been a growing problem for hospital systems in the post-pandemic era. Our institution began to have frequent platelet (PLT) shortages beginning in 2023. Transfusion Medicine physicians at our institution triaged PLT transfusion requests during critical shortages, and would approve the use of split PLT transfusions when unable to defer sufficient requests. Full single donor apheresis PLT units would be divided into equal 1/2 PLT units and provided to fulfil multiple requests for both therapeutic and prophylactic indications in adult patients. These 1/2 PLT units were similar in PLT content to the low dose PLTs used in the PLADO trial¹, which found no increased bleeding risk for patients receiving low dose prophylactic platelet transfusions. This IRB approved retrospective study evaluated split PLT unit transfusion outcomes at our institution.

Methods From 2023-2024, all patients receiving split PLT units were compared to a limited control population only receiving full PLT transfusions. Patient demographics, platelet counts, transfusion indications, and outcomes were obtained from electronic medical record review and compared using one-way ANOVA for statistical analysis. Transfusion indications were defined as prophylactic (PLT counts below goal), minor therapeutic(WHO grade 1 or 2 bleeding or urgent need for low risk procedure), and major therapeutic(WHO grade 3 or 4 bleeding or urgent need for surgery). Transfusion outcomes were defined as good(no new bleeding after prophylaxis, hemostasis achieved for minor or major bleeding, or successful procedure outcome),minor adverse outcome(additional PLT for prophylactic transfusions, mucosal bleeding(WHO 2 or less) after transfusion, or procedure delayed),or severe adverse outcome(continued bleeding or procedural bleeding complications).

Results148 patients were transfused 210 Split PLT units, with 95 patients receiving 132 prophylactic transfusions, 27 patients receiving 33 minor therapeutic transfusions, 33 patients receiving 45 major therapeutic transfusions. 52 control patients were transfused 201 full PLT units, with 18 patients receiving 118 prophylactic transfusions, 13 patients receiving 22 minor therapeutic transfusions, 28 patients receiving 61 major therapeutic transfusions. In both groups there were 7 patients with more than one transfusion indication during this time period. Patients receiving split PLTs were slightly younger(P<0.05), more likely outpatient(P<0.01), and had lower pre-transfusion PLT counts(28,123 K/uL vs 46,463 K/uL, P<0.01) but otherwise similar in sex, diagnosis, pre-transfusion WHO bleeding grades, and transfusion indication(P>0.05). The mean post-transfusion platelet counts were lower in the split PLT group(35,433 K/uL vs 59,678 K/uL, P<0.001) and the increase in PLT count after transfusion was lower in the split PLT group(7,310 K/uL vs. 13,216 K/uL, P<0.05). Transfusion outcomes were similar for split PLT compared to controls (Good outcome 155 split PLT vs 167 full PLT, Minor adverse outcome 30 split PLT vs 4 full PLT, and Major adverse outcome 25 split PLT vs 30 full PLT, P=0.44). Split PLT adverse outcomes were 24 major bleeding complications, 15 minor bleeding complications, 9 additional PLT transfusions, and 5 procedure delays. Control full PLT adverse outcomes were 30 major bleeding complications and 3 minor bleeding complications. A total of 3 allergic transfusion reactions occurred, with 1 non-severe and 1 severe for split PLTs and 1 non-severe for controls. There were no significant differences in post-transfusion WHO bleeding grades or transfusion reaction events.

Discussion Similar overall outcomes were found for our patients receiving split PLT transfusions compared to a limited control population. Split PLTs were provided for prophylactic and therapeutic transfusions, including patients with significant bleeding or need for major surgeries. This retrospective review provides some evidence for the tolerance of split PLT units during times of critical shortages. The small control population primarily had major adverse bleeding outcomes where the split PLT had similar minor and major adverse outcomes, likely limiting the generalizability of these results. The use of Split PLT transfusions appears to be a feasible option when other mitigation strategies have failed during critical platelet shortages.

1.Slichter etal.Dose of Prophylactic Platelet Transfusions and Prevention of Hemorrhage NEJM