The platelet count MUST BE AT LEAST 50,000!!

[yaah]

Gawd, this annoys me. There is no evidence out there to support the fact that minimally invasive procedures (like thoracentesis, LP, central line insertion) require a platelet count of 50,000 or higher in order to be done safely, yet here at this hospital the surgeons or radiologist frequently insist on having a platelet count of 50,000 before they will do the procedure. Today, this meant that they were requesting platelets for a woman with a count of 45,000 so that she could "safely" get her thoracentesis. This is such BS. Studies from years ago showed that a count of 20,000 is basically safe for procedures like this, and 50,000 is probably required for certain procedures like CABG or liver transplant.

So a frequent patient is the bone marrow transplant patient who hangs out at a platelet count of 20,000. Interventional radiology insists on a platelet count of 50,000 to do the procedure. We tell them the most effective way to do the procedure is to run in one 5 pack of platelets immediately before the procedure, if not concurrently with the procedure, as this provides the best results in someone who is going to consume any transfused platelets almost immediately. If the 5 pack bumps up their platelets to 50,000, if you were to check 2 hours later it would probably be back to 20,000 or whatever this person's steady state is. But they don't want the most effective results. They want a count of 50,000, even if that count was 3 hours prior to the procedure.

Case of the day: 17 year old boy with hemophagocytic syndrome. Platelet count averages 10-15 daily. Gets transfusions once a day or every other day, but the bump he gets is wiped out in 2 hours. Sample:
6am cbc: Platelets 15
11am transfusion of platelets (after rounds)
12:30 pm CBC after transfusion: platelets 40
1:30 pm CBC: Platelets 16.

Today, patient is getting a tracheostomy and LP in the OR. Surgeon demands "two five packs of platelets no later than 1pm" (surgery is at 3pm at the earliest) "as well as two five packs when patient gets to the OR to attain platelet count of at least 100,000." Both I and my attending talked to the staff yesterday about this patient, and how any operation will have to be done with platelet transfusion during the procedure, but not earlier in the day, because they will have no effect unless proximate to the surgery. We got FIVE calls today from residents and attendings, all asking for more platelets to "increase his counts prior to surgery." Every time we explained it to them, and every time they seemingly agreed. The deal: You will get 2 five packs of platelets when you get to the OR. Give him the first one while inducing anesthesia, run in the second one slowly during the procedure. If he bleeds following surgery, we will give more.

What do they do? Patient gets to OR at 3:30 pm, gets both 5 packs of platelets before 4pm. Incision is at 4:45. Nobody understands!

I blame the damn lawyers. Because the IR folks (and surgeons) have their hands tied. If there is a complication. They will ask "What was the preop platelet count?" Well, if the procedure was at noon and the last platelet count was at 6am and was 55,000 immediately after a transfusion, they can say, "55,000!" If the 6am count was 19,000 and the patient didn't get platelets until the OR, and no second count was drawn, they may very well get skewered for this. Damn lawyers. Show me the evidence you bloodsuckers!

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[b&ierstiefel]

dude, you need a beer.

scratch that.

you need something stronger.

 

[yaah]

I need platelets. 3 five packs stat. I have surgery in 8 hours.

We had an issue today also because there was a ruptured AAA which was eating up blood products and frankly, giving platelets to someone with a platelet count of 44 (recently checked, this time!) 1 hour prior to an ultrasound guided thoracentesis was not really a major priority.

Lawyers.


p.s. AAA rupture was 87 years old and required 60 RBC, 60 FFP, 10 platelet 5 packs before dying.

 

[LADoc00]

Dude, I have a serious gorked platelet tale. A resident on call for Trans Med and Coags gets a weekend call that a patient is not responding to platelets transfusions. Resident suggests perhaps it might be anti-platelet abs. Clinician demands ab testing, but resident explains this cant be done on a weekend. Clinician goes beserk and proceeds to chase the resident around the clin labs, resident cries and calls attending. Attending doesnt answer the page. Resident calls Lab Director, but he is out of town. Resident calls LADOC, but LADOC is drunk in a seedy part of SF and can only mutter "Youre screwed!" Patient dies hours later. Patient was a 30 year old woman who had just given birth and who's husband was a well known trial lawyer. Clinician writes cause of death on certificate "Died secondary to lack of ability to promptly receive blood products and appropriate testing." Resident is uncontrollably sobbing her career flashing before her eyes, chief resident tries to comfort her, LADOC begins praying in thanks he wasnt on call as he had traded that weekend on the schedule the prior month.

 

[yaah]

Holy crappola that's a bad story. Beats the hell out of mine.

I just wish they would stop treating the numbers so much and actually treat the damn patient! I realize that if someone has a count of 6 they may need platelets. But a count of 35,000 doesn't mean they need a transfusion to get a bone marrow biopsy.

Top request so far this month:

Pt's platelet count on sunday: 76
Platelet count on monday, 7am (without transfusion) 86.
Pt on monday is due to have an EGD at noon. Resident calls down demanding platelets because they need a count of 100,000 to "avoid duodenal hematomas" and thus require platelets now (it is now 8am) to get the count above 100,000 prior to the procedure. Part of the reason: "His platelet count has been trending down daily." Yeah, like today's? Asshats.

 

[bananaface]

Treat the patient not the numbers? Oooh. Sounds like clinical speak to me.

yaah + clinical medicine =

Did mousey break it to you that she is interested in forensics? I told her you liked CSIs.

 

[tsj]

CP is for wimps

 

[yaah]

CP is for wimps

You would change your tune if you saw my blood bank attending this week in action. Holy cow she is a pit viper.

 

[f_w]

Maybe it is a local phenomenon.

On hemonc patients, most IR's will do a thora or paracentesis with 20k platelets or less. That is if they have the knowledge that the platelets they ordered are in fact available if it doesn't stop squirting.

Just as there are plenty of 'funny clinican' stories out there, there are plenty of 'a%#$#*% CP resident' stories out there. Part of the obsession with having a number to stare at before the case is the experience of being left hi and dry before (while the CP resident who has to 'approve' the dispensing of the already ordered and 'approved' platelets is having dinner at Gennaro's)

(I have seen someone with 50k platelets bleed to death in front of our eyes from a 'minimally invasive procedure'.)

What I have done before in angio cases on borderline patients was to draw CBC and coags while gaining access (before hooking up the hep-saline). That way, I had an idea about the situation before pulling the sheath an hour later. Pulling the sheath is were you get into trouble if you run low on platelets, not during the procedure itself (barring a perf).





I blame the damn lawyers. Because the IR folks (and surgeons) have their hands tied. If there is a complication. They will ask "What was the preop platelet count?" Well, if the procedure was at noon and the last platelet count was at 6am and was 55,000 immediately after a transfusion, they can say, "55,000!" If the 6am count was 19,000 and the patient didn't get platelets until the OR, and no second count was drawn, they may very well get skewered for this. Damn lawyers

At least your wrath is directed towards the correct target.

 

[yaah]

People with 50k platelet counts bleed out all the time - but it isn't necessarily because of the platelet count. A platelet count of 50,000 should provide adequate hemostasis but even with a count of 450k you can easily bleed out.

The nasty patients are the ones with inhibitors. We are following a patient in blood bank with a VWF inhibitor. Insanity. Her medical bills I think are about $200k per day.

Evil blood bank patients of the day:

1) Sickle Cell Anemia patient with the following antibodies: Jka, K, c, S, Fya, Fyb, E. The clinicians want to give her a bone marrow transplant. There is no compatible blood for her. She is like Bombay.

2) Woman who came in with ITP and has an Anti-HI antibody (an ALLO antibody). No blood for her either.

 

[b&ierstiefel]

way to be judgmental, tough guy.

 

[yaah]

If this woman gets a bone marrow transplant it may help her, but she probably would not survive the induction and consolidation chemotherapy because she would need to be supported with blood transfusions, which she would probably hemolyze.

 

[yaah]

They did it again today.

AM count: 18
Thoracentesis scheduled for the afternoon (pt is a BMT recipient who hasn't engrafted yet and has sepsis and consumes platelets)
Previous days have seen him have a count of 15-20 and every platelet transfusion results in a bump of about 5-8000 which lasts about an hour.

Tranfuse 1 five pack: Post count 26
At this point they call and request two more 5 packs because interventional radiology won't do it without a count of 50,000.

Thus, they want to give this man at least 4 five packs, even though platelets survive in his system for about an hour, so that they can see a count of 50,000 before they do the procedure, even though by the time they do the procedure the count will be back below 40 if not 30 if they were to check it (which they won't).

BB attending's suggestion: hang platelets during the procedure. We won't release more just so you can get a count because it might take a lot more than two, and he has already gotten two which have basically been wasted and given him more donor exposures.

IR's suggestion: Cancel the procedure.