Expressing concern that dengue patients are being transfused platelets inappropriately and against international guidelines, the Sindh Blood Transfusion Authority (SBTA) has said platelets may only be transfused if a patient bleeds during the course of the disease or if their platelet count drops below 20,000 per cubic millimetre (mm³).
“With the increase in the number of dengue patients following a dengue fever outbreak in Sindh, especially in Karachi, it has been observed with great concern that dengue patients are being transfused platelets inappropriately and not as per guidelines and indications,” SBTA Secretary Dr Dur-e-Naz Jamal has written to Sindh’s medical superintendents.
“This practice should be discouraged at all levels throughout the province to decrease the over consumption of platelets as well as to minimise the load on blood banks.”
Around 99 per cent of dengue patients do not need platelet transfusion even if their platelet count drops to 10,000/mm³ — or even lower — if there is no sign of bleeding from their gums or nose, spots or bruising on the skin, or blood in the urine, experts said on Saturday.
Hundreds of people are getting infected with the dengue virus in Pakistan on a daily basis following the unprecedented rains. Health authorities in Karachi say that the number of dengue cases was three to four times higher this month until Saturday when compared to the entire last month.
The SBTA said blood banks in the city provided 29,000 units of platelets last month alone after hospitals asked the attendants of dengue patients to start arranging mega or single units of platelets.
However, the SBTA added, they are asking blood banks not to issue platelet units without clinicians’ advice because several people have been asking for platelets without any medical requirement.
“In dengue fever, platelets can be given to prevent bleeding before bleeding happens or to stop the bleeding in patients who are bleeding,” infectious diseases expert Dr Faisal Mahmood of the Aga Khan University Hospital said.
“As far as prevention of bleeding is concerned, there is no cut-off of platelet count. The World Health Organisation and we clinicians believe that there is no reason to transfuse platelets to any dengue patient who is not bleeding.”
He said that if a person is bleeding and their platelet count is below 100,000/mm³, they should be given platelets, otherwise there is no need to transfuse platelets to every patient.
“Actually, the risk of bleeding in dengue patients is not related to platelet count. If a patient needs to bleed, they will bleed even at a higher platelet count, while in many patients they don’t bleed even if their platelet count drops below 10,000/mm³.”
Replying to a query, he said that very few patients among thousands of patients require platelet transfusion, adding that he has not even transfused platelets on single digits because the patients were not bleeding.
Professor of Medicine Dr Tahir Hussain said platelet transfusion is only required when there is a high risk of major bleeding in susceptible patients, adding that there is no absolute platelet count on which they are necessary.
“Generally, if the dengue patient has or is at risk of a major bleed in the judgment of the physician, platelet therapy is deemed necessary. In 99 per cent of otherwise healthy patients, it’s not required.”
Dr Naseem Salahuddin was of the same opinion, saying that a doctor treating a dengue patient should start worrying when there is nosebleed, bleeding gums, spots or bruising on the skin, bleeding into the conjunctiva of the eyes, black stool or blood in the urine, along with falling platelets.
“Low platelets by themselves don’t mean a transfusion is required. All physicians should be trained to recognise when to transfuse platelets and when not to. The most important advice is to replace balanced amount of fluid and fever reduction,” the Indus Hospital Karachi head of infectious diseases said. “Of the thousands of dengue patients I’ve handled over the years, I must’ve transfused less than 20. Over 98 per cent of the patients survive without complications, and the platelets return to normal within eight to 10 days,” she said.
“Of course, you always instruct patients about the warning signs and to return immediately if any of these happen, that is bleeding, hypotension, decreased urine, abdominal pain, shortness of breath, etc.”
Pakistan Society of Internal Medicine General Secretary Dr Somia Iqtidar said that in dengue fever, platelets and white blood cells start decreasing but people believe that if their patients are given platelets, they can be cured, which is incorrect.
“To increase platelets, people use many home remedies like papaya leaf juice, pomegranate juice and apple juice, as well as platelet transfusion, but they don’t prove beneficial for the patient because platelets are produced in the bone marrow and start increasing once the viral infection subsides on its own with the passage of time.”
She also pointed out that in the second phase of the dengue illness, platelets in the blood circulating in the body also start getting destroyed and their count decreases. She advised patients and their attendants not to force doctors and other medical professionals to transfuse platelets because the experts know when and which patient needs platelet transfusion.
— Reporting by M. Waqar Bhatti