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Patel H, Radadiya D. Estimating the Penalties of Cytopenias Pre-endoscopy: Is Enough Known? Dig Dis Sci 2024:10.1007/s10620-024-08461-2. [PMID: 38739231 DOI: 10.1007/s10620-024-08461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Harsh Patel
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Dhruvil Radadiya
- Division of Gastroenterology, Hepatology and Motility, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA.
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2
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Loganathan P, Mohan BP, Alderman D, Gajendran M, Moond V, Adler DG. Safety of Endoscopic Procedures in Thrombocytopenia and Neutropenia: Embracing Assurance. Dig Dis Sci 2024:10.1007/s10620-024-08467-w. [PMID: 38739232 DOI: 10.1007/s10620-024-08467-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/26/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Few studies have evaluated the post-endoscopic adverse events in patients with neutropenia and thrombocytopenia. Current guidelines do not provide clear direction on this topic. AIM We explore the pooled rates of safety and adverse effects of endoscopic interventions in thrombocytopenia and neutropenia patients via a systematic review & meta-analysis. METHODS Databases, including Medline, Scopus, and Embase, were searched (in May 2023) using specific terms for studies evaluating the clinical outcomes of endoscopy in patients with thrombocytopenia and neutropenia. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity. RESULTS Six studies and four studies evaluated endoscopic outcomes in patients with thrombocytopenia and neutropenia respectively with mean age was 56 years. The pooled rate of total post-biopsy bleeding and total post-polypectomy bleeding among patients with thrombocytopenia was 4% (95% CI 1-11), I2 = 84%, and 12% (95% CI 3-36) I2 = 43%. The total rate of post procedure-related bleeding in thrombocytopenia was 5% (95% CI 1-14) I2 = 95%. The pooled rate of post-endoscopic infection (fever from any cause, bacteremia) in neutropenia was 10% (95% CI 3-28%) I2 = 96%. On sub analysis, the pooled rate of bacteremia and 30 days all-cause mortality in neutropenia was 4% (95% CI 3-5%) I2 = 0% and 13% (95% CI 4-34%) I2 = 95% respectively. CONCLUSION Our data supports the notion that endoscopic procedures are safe for neutropenic, thrombocytopenic patients with suitable indications and reasonable functional status and have an acceptable risk/benefit ratio.
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Affiliation(s)
| | - Babu P Mohan
- Gastroenterology & Hepatology, Orlando Gastroenterology PA, Orlando, FL, USA
| | - David Alderman
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Mahesh Gajendran
- Gastroenterology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Vishali Moond
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, NJ, USA
| | - Douglas G Adler
- Gastroenterology, Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA.
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Patel A, Treves G, Samreen I. The Safety of Endoscopic Procedures in Patients With Thrombocytopenia: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e51773. [PMID: 38322081 PMCID: PMC10844715 DOI: 10.7759/cureus.51773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Endoscopic procedures are essential in gastroenterology but pose significant risks for thrombocytopenic patients who have lower platelet counts, increasing the likelihood of bleeding complications. This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess bleeding risks in thrombocytopenic patients undergoing various endoscopic procedures. A comprehensive search was conducted across databases like PubMed, MEDLINE, and EBSCO, using stringent criteria for inclusion and exclusion, with study quality assessed via the Newcastle-Ottawa Scale and thrombocytopenia severity classified by Common Terminology Criteria for Adverse Events (CTCAE) criteria. Statistical analysis focused on bleeding event incidence rates at different platelet count thresholds, utilizing RevMan Web (Cochrane, London, UK) and Excel (Microsoft® Corp., Redmond, WA). The search yielded 1,675 potential articles, but only three retrospective cohort studies were selected. Results showed a significant increase in bleeding risk for patients with platelet counts below 50,000/mm3, particularly under 25,000/mm3, with a 5.5% prevalence of post-procedure bleeding in moderate to severe thrombocytopenic patients versus 4.0% in those with higher counts, and a threefold higher risk in severe thrombocytopenia. The study highlights the need for meticulous pre-procedure assessments in thrombocytopenic patients and points out disparities in guideline recommendations, suggesting personalized approaches based on patient-specific risks. It underscores balancing diagnostic yield against bleeding risks, especially in severe thrombocytopenia, and discusses the controversial role of prophylactic platelet transfusions, advocating for a nuanced approach. In conclusion, this meta-analysis provides critical insights into managing thrombocytopenia in endoscopic procedures, emphasizing the importance of individualized patient assessment and adherence to evolving guidelines, and underlining the necessity of further research to refine these guidelines and improve patient safety and outcomes in this challenging clinical scenario.
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Affiliation(s)
- Akash Patel
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Guy Treves
- Internal Medicine, Eisenhower Health, Rancho Mirage, USA
| | - Isha Samreen
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
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4
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AbiMansour JP, Garimella V, Petersen BT, Law RJ, Storm AC, Martin JA, Levy MJ, Abu Dayyeh BK, Chandrasekhara V. Risk of post-sphincterotomy bleeding in patients with thrombocytopenia. Ther Adv Gastrointest Endosc 2023; 16:26317745231200971. [PMID: 37767287 PMCID: PMC10521278 DOI: 10.1177/26317745231200971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/26/2023] [Indexed: 09/29/2023] Open
Abstract
Background Reports suggest that the rate of adverse events (AEs) post-endoscopic sphincterotomy (ES) to be as high as 10%, with gastrointestinal bleeding being most common after post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. Objective The aim of this study was to characterize the incidence of bleeding in patients with thrombocytopenia following ES. Design Retrospective observational cohort study. Methods Patients with thrombocytopenia (defined as <150,000 platelets/μL) who underwent ES between May 2017 and December 2020 were identified at a tertiary care medical center. The incidence of immediate (intraprocedural oozing >5 min or requiring intervention) or delayed (clinical bleeding with associated hemoglobin drop within 14 days) post-ES bleeding was determined via manual chart review. Results A total of 221 patients with a mean platelet count of 108,000 ± 13,000 platelets/μL underwent ERCP with ES. Immediate bleeding occurred in 11 (5%) patients with no significant drop in hemoglobin or transfusion requirement. Two patients (0.9%), both of whom were noted to have immediate bleeding, also developed delayed bleeding. Presence of malignancy was associated with an increased risk of bleeding (36.4% versus 11.4%, p = 0.037) while platelet count was not. Conclusion In a cohort of patients with thrombocytopenia, rates of immediate and delayed bleeding are similar to previously reported AE rates of ES in the general patient population. Careful attention should be given to patients with a history of active malignancy as well as those who develop immediate bleeding as they appear to be at increased risk for bleeding complications.
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Affiliation(s)
- Jad P. AbiMansour
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Vishal Garimella
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Bret T. Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - John A. Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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Abstract
Platelets are commonly transfused either therapeutically or prophylactically to maintain hemostasis. Most platelet transfusions are used to manage patients with hematologic malignancies. Although platelet transfusion guidelines have been published, platelet transfusion practices are still heterogeneous. Platelet transfusion guidelines partly lack recommendations or differ in the platelet threshold recommendations in some clinical situations. This article reviews platelet transfusions focusing on transfusion guidelines and platelet thresholds in different clinical settings.
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Affiliation(s)
- Shan Yuan
- Division of Transfusion Medicine, Department of Pathology, City of Hope National Medical Center, Duarte, CA 91010-3000, USA
| | - Zaher K Otrock
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Henry Ford Hospital, K6, 2799 West Grand Boulevard, Detroit, MI 48202, USA; Department of Pathology, Wayne State University School of Medicine, Detroit, MI, USA.
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6
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Rajan AV, Trieu H, Chu P, Lin J, Kidambi TD. Assessing the yield and safety of endoscopy in acute graft- vs-host disease after hematopoietic stem cell transplant. World J Gastrointest Endosc 2020; 12:341-354. [PMID: 33133371 PMCID: PMC7579526 DOI: 10.4253/wjge.v12.i10.341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute gastrointestinal (GI) graft-vs-host disease (aGVHD) is the most complication of hematopoietic stem cell transplant (HSCT) in patients with hematologic malignancy. Limited data exists on endoscopic evaluation of GVHD in post-HSCT patients with differing GI symptoms. Further, the diagnostic value of gross endoscopic findings as well as the safety of endoscopy in this commonly thrombocytopenic and neutropenic patient population remains unclear.
AIM To understand the diagnostic value of symptoms and gross endoscopic findings as well as safety of endoscopy in aGVHD patients.
METHODS We analyzed 195 endoscopies performed at City of Hope in patients who underwent allogeneic HSCT less than 100 d prior for hematologic malignancy and were subsequently evaluated for aGVHD via endoscopy. The yield, sensitivity, and specificity of diagnosing aGVHD were calculated for upper and lower endoscopy, various GI tract locations, and presenting symptoms.
RESULTS Combined esophagogastroduodenoscopy (EGD) and flexible sigmoidoscopy (FS) demonstrated a greater diagnostic yield for aGVHD (83.1%) compared to EGD (66.7%) or FS (77.2%) alone with any presenting symptom. The upper and lower GI tract demonstrated similar yields regardless of whether patients presented with diarrhea (95.7% vs 99.1%) or nausea/vomiting (97.5% vs 96.8%). Normal-appearing mucosa was generally as specific (91.3%) as abnormal mucosa (58.7%-97.8%) for the presence of aGVHD. Adverse events such as bleeding (1.0%), infection (1.0%), and perforation (0.5%) only occurred in a small proportion of patients, with no significant differences in those with underlying thrombocytopenia (P = 1.000) and neutropenia (P = 0.425).
CONCLUSION Combined EGD and FS with biopsies of normal and inflamed mucosa demonstrated the greatest diagnostic yield regardless of presenting symptom and appears to be safe in this population of patients.
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Affiliation(s)
- Anand V Rajan
- Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
- Department of Medicine, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
| | - Harry Trieu
- Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
- Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States
| | - Peiguo Chu
- Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
| | - James Lin
- Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Trilokesh Dey Kidambi
- Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
- Department of Gastroenterology, City of Hope, Duarte, CA 91010, United States
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Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
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Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
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8
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Safety of Transesophageal Echocardiography in Patients with Thrombocytopenia. J Am Soc Echocardiogr 2019; 32:1010-1015. [DOI: 10.1016/j.echo.2019.04.421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/17/2019] [Accepted: 04/19/2019] [Indexed: 01/09/2023]
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9
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Safety of endoscopy in cancer patients with thrombocytopenia and neutropenia. Gastrointest Endosc 2019; 89:937-949.e2. [PMID: 30550744 DOI: 10.1016/j.gie.2018.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 12/02/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Cancer patients are prone to thrombocytopenia and neutropenia, which increase the risk of bleeding and infection. We assessed the safety of endoscopic procedures in cancer patients with thrombocytopenia and/or neutropenia. METHODS We studied consecutive cancer patients with thrombocytopenia and/or neutropenia who underwent endoscopic procedures from 2010 through 2015. Neutropenia was defined as an absolute neutrophil count (ANC) <1000 cells/μL, and thrombocytopenia as a platelet count <100 × 103/μL. Univariate and multivariate generalized estimating equation models were used to assess factors associated with risk of adverse events (AEs) or death. RESULTS We identified 588 patients who underwent 783 procedures; 608 procedures were performed in the setting of thrombocytopenia and 675 procedures in the setting of neutropenia. Concurrent neutropenia and thrombocytopenia were recorded in 500 endoscopies. Twenty-four patients (4.1%) experienced infectious AEs, whereas 29 (4.9%) experienced bleeding AEs within 1 week of the procedure. On multivariate analysis, platelet count ≤50 × 103/μL was associated with risk of bleeding AEs. In contrast, poor performance status was associated with increased risk of infection AEs (P < .01). No association was observed between low ANC and infectious AEs. Poor performance status (P < .01) and platelet count ≤100 × 103/μL (P < .05) were associated with increased risk of 30-day mortality. A persistent platelet count <20 × 103/μL after the procedure, with a baseline platelet count of ≤20 × 103/μL before the procedure, was associated with significant risk of bleeding AEs compared with a platelet count >20 × 103/μL after the procedure (P < .01); furthermore, if the platelet count increased to >50 × 103/μL after the procedure, the bleeding risk after the procedure was greatly reduced (P < .01). CONCLUSIONS Endoscopic procedures are relatively safe in cancer patients with platelet count >50 × 103/μL. Nevertheless, a platelet count of ≥20 × 103/μL could be an appropriate threshold for platelet transfusion if 50 × 103/μL is difficult to achieve. The functional status of the patient, in the absence of the need for urgent or necessary endoscopic interventions, should be considered when deciding whether to perform endoscopy. The risk of procedure and the ANC did not seem to affect the outcomes.
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10
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Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr 2019; 68:595-606. [PMID: 30664560 PMCID: PMC8597353 DOI: 10.1097/mpg.0000000000002277] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pediatric gastrointestinal endoscopy has been established as safe and effective for diagnosis and management of many pediatric gastrointestinal diseases. Nevertheless, certain patient and procedure factors should be recognized that increase the risk of intra- and/or postprocedural adverse events (AEs). AEs associated with endoscopic procedures can broadly be categorized as involving sedation-related physiological changes, bleeding, perforation, and infection. Factors which may increase patient risk for such AEs include but are not limited to, cardiopulmonary diseases, anatomical airway or craniofacial abnormalities, compromised intestinal luminal wall integrity, coagulopathies, and compromised immune systems. Examples of high-risk patients include patients with congenital heart disease, craniofacial abnormalities, connective tissues diseases, inflammatory bowel disease, and children undergoing treatment for cancer. This clinical report is intended to help guide clinicians stratify patient risks and employ clinical practices that may minimize AEs during and after endoscopy. These include use of CO2 insufflation, endoscopic techniques for maneuvers such as biopsies, and endoscope loop-reduction to mitigate the risk of such complications such as bleeding and intestinal perforation. Endoscopic infection risk and guidance regarding periprocedural antibiotics are also discussed.
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11
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Laine L. Treatment of thrombocytopenic patients with GI bleeding. Gastrointest Endosc 2018; 88:62-65. [PMID: 29935628 DOI: 10.1016/j.gie.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA; Veterans Administration Connecticut Healthcare System, West Haven, Connecticut, USA
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12
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Outcomes of endoscopic intervention for overt GI bleeding in severe thrombocytopenia. Gastrointest Endosc 2018; 88:55-61. [PMID: 29408558 DOI: 10.1016/j.gie.2018.01.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Gastrointestinal bleeding (GIB) in the setting of thrombocytopenia raises concerns about endoscopic procedure risk. We aimed to assess the safety and outcomes of endoscopy for overt GIB in the setting of severe thrombocytopenia in liver cirrhosis (LC) and non-liver cirrhosis (NLC). METHODS This is a retrospective study on inpatients who underwent endoscopy within 24 hours of presentation for overt GIB with a platelet count (PC) of 20 to <50 × 103/mL. Outcomes included diagnostic and therapeutic yields, procedural adverse events, packed red blood cell (pRBC) and platelet transfusions, recurrent bleeding rate, and all-cause and GIB-related mortality. RESULTS One hundred forty-four patients were identified. The median PC was 41 × 103/mL and 61% had LC. The diagnostic yield was 68% (LC = 61%, NLC = 79%, P = .04). Therapeutic yield was 60% (59% vs 60%, P = 1.00). The initial hemostasis rate was 94% with one adverse event. The median number of pRBC and platelet transfusions decreased after intervention in the entire cohort. Recurrent bleeding rates were 22% at 1 month and 30% at 1 year, with no differences between groups. An increased international normalized ratio (INR) >2 was a predictor of recurrent bleeding. All-cause mortality was 19% at 1 month and 37% at 1 year, whereas GIB-associated mortality in our cohort was only 3% at 1 month and 4% at 1 year, with no significant difference between LC and NLC. Predictors of mortality were INR >2, activated partial thromboplastin time >38 seconds, hypotension, intensive care unit admission, and pulmonary comorbidities. CONCLUSION In this study cohort, we observed that endoscopy for overt GIB in the setting of severe thrombocytopenia in patients with LC and NLC appears safe, has moderate diagnostic and therapeutic yields with high initial hemostasis rate, and is associated with a significant decrease in pRBC and platelet transfusions. Recurrent bleeding and all-cause mortality rates remain high.
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Schiffer CA, Bohlke K, Delaney M, Hume H, Magdalinski AJ, McCullough JJ, Omel JL, Rainey JM, Rebulla P, Rowley SD, Troner MB, Anderson KC. Platelet Transfusion for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2018; 36:283-299. [DOI: 10.1200/jco.2017.76.1734] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose To provide evidence-based guidance on the use of platelet transfusion in people with cancer. This guideline updates and replaces the previous ASCO platelet transfusion guideline published initially in 2001. Methods ASCO convened an Expert Panel and conducted a systematic review of the medical literature published from September 1, 2014, through October 26, 2016. This review builds on two 2015 systematic reviews that were conducted by the AABB and the International Collaboration for Transfusion Medicine Guidelines. For clinical questions that were not addressed by the AABB and the International Collaboration for Transfusion Medicine Guidelines (the use of leukoreduction and platelet transfusion in solid tumors or chronic, stable severe thrombocytopenia) or that were addressed partially (invasive procedures), the ASCO search extended back to January 2000. Results The updated ASCO review included 24 more recent publications: three clinical practice guidelines, eight systematic reviews, and 13 observational studies. Recommendations The most substantial change to a previous recommendation involved platelet transfusion in the setting of hematopoietic stem-cell transplantation. Based on data from randomized controlled trials, adult patients who undergo autologous stem-cell transplantation at experienced centers may receive a platelet transfusion at the first sign of bleeding, rather than prophylactically. Prophylactic platelet transfusion at defined platelet count thresholds is still recommended for pediatric patients undergoing autologous stem-cell transplantation and for adult and pediatric patients undergoing allogeneic stem-cell transplantation. Other recommendations address platelet transfusion in patients with hematologic malignancies or solid tumors or in those who undergo invasive procedures. Guidance is also provided regarding the production of platelet products, prevention of Rh alloimmunization, and management of refractoriness to platelet transfusion ( www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki ).
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Affiliation(s)
- Charles A. Schiffer
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Kari Bohlke
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Meghan Delaney
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Heather Hume
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Anthony J. Magdalinski
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Jeffrey J. McCullough
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - James L. Omel
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - John M. Rainey
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Paolo Rebulla
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Scott D. Rowley
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Michael B. Troner
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
| | - Kenneth C. Anderson
- Charles A. Schiffer, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI; Kari Bohlke, American Society of Clinical Oncology, Alexandria, VA; Meghan Delaney, Children’s National Medical System & George Washington University, Washington DC; Heather Hume, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada; Anthony J. Magdalinski, Alliance Cancer Specialists, Sellersville, PA; Jeffrey J. McCullough, University of Minnesota, Minneapolis, MN; James L. Omel,
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14
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Oh HJ, Park JM, Yoon SB, Lee HH, Lim CH, Kim JS, Cho YK, Lee BI, Cho YS, Choi MG. Bleeding After Endoscopic Procedures in Patients With Chronic Hematologic Thrombocytopenia. Dig Dis Sci 2017; 62:746-754. [PMID: 28035550 DOI: 10.1007/s10620-016-4427-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Procedure-induced bleeding is a major complication after endoscopic intervention. AIMS The aim of this study was to investigate the risk of endoscopy-related bleeding in patients with chronic hematologic thrombocytopenia. METHODS We investigated endoscopy-related bleeding in 175 procedures performed on 108 patients with immune thrombocytopenic purpura or aplastic anemia. The outcomes were compared with those of 350 procedures on age-, sex-, and procedure-matched control subjects. Endoscopic interventions included low-risk procedures such as endoscopic biopsy and high-risk procedures including polypectomy, endoscopic resection, and endoscopic retrograde cholangiopancreatogram with sphincterotomy. RESULTS Bleeding occurred in 17 (9.7%) procedures among the patients with thrombocytopenia. This rate was significantly higher than that in procedures on controls (3.1%, P = 0.003). About 60% of all bleeding events were observed within 24 h after the endoscopic procedure. Bleeding after endoscopic biopsy developed more frequently in the patient group than in the control group (7.1 vs. 0.7%; P < 0.001). Bleeding occurred after 20% of all high-risk procedures. The incidence of bleeding was significantly elevated in patients with a platelet count less than 50 × 103/μl. Multivariate analysis revealed that high-risk procedures and low platelet count (less than 50 × 103/μl) were significantly related to procedure-related bleeding. All bleeding events stopped spontaneously or were controlled with endoscopic hemostasis. CONCLUSIONS Endoscopic procedure-related bleeding develops frequently in patients with chronic hematologic thrombocytopenia. Post-procedural bleeding should be observed carefully in these patients, especially when the platelet count is less than 50 × 103/μl or high-risk endoscopic procedures are planned.
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Affiliation(s)
- Hyun Jin Oh
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea.
| | - Seung Bae Yoon
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Han Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Jin Su Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Young-Seok Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea
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15
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Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.
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Affiliation(s)
- Selvi Thirumurthi
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
| | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA.
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