Optimizing the Use of Platelets in a Single Oncology Center during Critical Shortages: Can Current Platelet Donations from Volunteer Donors be Sustained to Provide Adequate Platelet Inventories Long Term?

Introduction: The single largest use of platelets transfusions (PLT) are for patients with hematologic malignancies receiving Myeloablative chemotherapy or undergoing hematopoietic stem cell transplantation (HSCT). Patients routinely get prophylactically platelet transfusions at platelet counts ≤ 20 × 10⁹/L at our institution per institutional guidelines. For this review we analyzed a two day period when a critical shortage of platelets occurred to illustrate how we managed the transfusion needs of our patients.

Method

All daily platelet orders are triaged. The orders are inclusive of patient demographics, indication(s) for transfusion and pertinent lab results (most recent H/H, PLT count, PT/INR/PTT, fibrinogen, D-Dimer, Creatinine and BUN). The location of the patient and indications (ICH Hemorrhage/coagulation abnormalities) further allows the Blood Bank to prioritize the release of platelets. The orders are sorted by counts ≤5K, 6-10K, 11-20K, 21-30K, 31-40K, 51-60K and >61K and then categorized by location (EC, Surgery/Outpatients and disease (Hematologic malignancies/HSCT/other neoplasms). A reduction of the Random Donor Platelet (RDP) inventory by 50% is considered critical especially when daily shipments from our contracted blood suppliers are delayed or reduced.

Our regular platelet inventory consist mainly of RDPs with 5-10% of Single Donor Apheresis platelets (SDPs). Our daily transfusion needs consists of 400 to 700 RDPs with a reduction on weekends. Due to the volume of our daily platelet transfusion our needs cannot be met by SDPs only.

Results:

We received 269 platelet transfusion orders within the two day critical shortage period. The bulk of the orders were received between 4-10 am. The majority (93%) were from patients undergoing treatment for hematologic malignancies of which 18% were from HSCT patients. A total of 474 RDP were transfused to 176 (66%) patients, median of 3 (range 2-4 pooled RDPs), 57 (32%) received 2 pooled RDPs, 116 (66%) received 3 pooled RDPs and 3 (2%) patients received 4 pooled RDPs. Of the 269 patients 82 (30%) were transfused with SDPs. There were 2 duplicate orders and 9 (3.3%) patients did not receive platelets on the requested day. The majority of the platelet orders (85.5%) were for platelet counts =<20 K/uL, followed by Intracranial hemorrhage (4%), active bleeding (3.4%) and bone marrow biopsy (2.6%) and LP/Solid Organ biopsy/Spinal Surgery/Others (each <1%). The reduction in the number of pooled RDPs did not lead to adverse events.

Discussion:

When the platelet inventory is at par, patients receive 4 pooled RDP units as prophylactic transfusion for counts ≤ 20K. When the inventory falls to below 50% of par, the number of pooled RDPs is decreased to 3 for actively bleeding patients and for those with counts ≤10 K/L. The pools are further decreased to 2-3 RDP units for counts 11-20 K based on inventory. Electronic notification is sent to primary providers to call the Transfusion Medicine Physician when the reason for transfusion does not meet institutional guidelines.

The current platelet stock management is heavily dependent on whole blood donations from which RDPs are processed. High school students currently contribute 10% of the US blood supply which may increase up to 20% during the spring/fall months. The most important question that needs to be discussed and addressed before it leads to a crisis is the sustainability of Platelets donations from volunteer donors. Donor Centers around the United States have seen a gradual decline in volunteer donors with aging of the volunteer donor pool. Only 4-6% of eligible donors in the US currently donate blood and this is projected to decrease in the next five years. The TRALI mitigation strategy eliminated many eligible females from donating whole blood/platelets and now the Iron mitigation strategy will also impact the volunteer donor pool. One avenue that could be explored for platelet acquisition would be to accumulate a dedicated pedigreed/trusted pre-screened repeat pool of paid donors similar to the concept used by US plasma centers. This will be a major paradigm shift, be problematic in the beginning as the model is not being used currently in the US for platelet donations. However, with the ever increasing need for platelet transfusion, altruistic appeals alone may be insufficient to meet the demands of blood and platelets. This concept may not be too farfetched in the near future and begs to be considered.