Vitalant as blood supplier - low yield and compensated donor platelets

[RRay]

Anyone else using Vitalant?  We do partially.  Wanted to know if you've gotten any information on how frequent this low-yield supply will be?

I get why they're supplementing inventory with these, but I'm having trouble getting information from my account rep.

This involves a lot more than just turning on product codes for us, so putting out feelers.  We're so remote I don't have a good network of other users.

[Neil Blumberg]

We routinely use half dose of apheresis platelets as our standard therapy.  Approved by our medical staff overall. Less toxicity, lower cost, equal efficacy.  What do you believe you need to do other than having a separate code?

[RRay]

Our medical director wants us to document notification to provider that the product is low yield.  Having to set up a trigger point for a  required comment box.

Problem with vitalant is they cut off all the yield tags before they get to us so there's nothing really to flag to staff that these are low yield.  Its hard to expect generalists that work blood bank 1-2 days a month to memorize the codes.  

And to your point about cost... Vitalant is charging the same for low yield vs standard PLTs.

[RRay]

@Neil Blumberg What indications are you using these half-doses for mainly?  All indications?

I ask because the main reason our med director wants the provider notified is that around half of our platelet transfusion is pre-procedure to meet platelet count requirements.  The other half goes to our infusion center.  

[jshepherd]

Hey Randi, 

I would push back on your medical director if you can. To Dr. Blumberg's point, low-yield platelets are an FDA approved product, so there's no real reason to require notification to providers, especially if half the infusions are just topping up people for a procedure, but I won't rant about that one right now.  

Agreed that Vitalant was not clear about how often they expect to have these, and their cost being the same. We don't order from Vitalant much, but we haven't seen any of the new E-codes for low yield. 

Janine

[RRay]

31 minutes ago, jshepherd said:

 I would push back on your medical director if you can. To Dr. Blumberg's point, low-yield platelets are an FDA approved product, so there's no real reason to require notification to providers, especially if half the infusions are just topping up people for a procedure, but I won't rant about that one right now.  

I agree, I hate arbitrary lvls for surgery.  I'll see who is requesting the notification specifically and see if I can get some data to them.  I know the medical director is being the messenger in this scenario.  I have it a feeling it's OR docs... it's always OR docs.

[Neil Blumberg]

This is operationally difficult as there are all sorts of guidelines in the literature, many from professional societies recommending platelet transfusion at different platelet counts for surgery and invasive procedures.  It's hard for practitioners to ignore these, for medicolegal reasons,  and instead, practice what we now know is better medicine (no transfusion in most patients).  I've been involved with thrombocytopenic patients and their treatment for 50 years.  I'm here to tell you that, regrettably, existing expert opinion and platelet count based guidelines are almost total scientific and clinical nonsense.  Strong words, but driven by recent, actual data and extensive clinical experience and research.

How should we evaluate the risk of bleeding in patients undergoing surgery?  It isn't the laboratory tests, although they can be useful when there is evidence from the history and physical exam that there is a hemostatic problem.  Patients whose skin and mouth show no evidence of bleeding/purpura/petechia, and have no personal or family history of bleeding problems,  almost never bleed unless something goes wrong during the procedure. Indeed, the bleeding rate for many high risk procedures (liver biopsy, kidney biopsy, etc.) is very low in terms of patients who need an intervention such as transfusion, surgery, etc. 

So we are treating 100% of patients with plasma or platelets or both in the vain hope of preventing bleeding, which happens in perhaps 1, 5 or 10% of patients or fewer. This is sub-optimal medicine, as platelet transfusion (and plasma transfusion) are high risk therapies that can, in rare instances, kill patients. 

Transfusion should be driven by actual bleeding and timely hemostatic evaluation (mostly things like TEG, ROTEM, Quantra with occasionally useful tests such as PT, PTT, fibrinogen, platelet count, platelet function testing such as closure time, factor XIII level).  Prophylactic transfusion in this setting is unnecessary and unlikely to help, and very likely to harm. Don't do it is my advice, despite the guidelines,  which have no evidence base whatever and represent a tragic, well intentioned misunderstanding of hemostasis and transfusion efficacy and safety.

So what this means for half doses of platelets is that they can be used in almost everyone with equal efficacy and reduced risk of harm.  We do this all the time for the last few years,  and have bleeding rates that are far below those in the literature because we use only ABO identical platelets.  ABO mismatched platelets actually increase rather than prevent or treat bleeding.  Our bleeding rate in prophylactic transfusions is <5% compared with 70% in the PLADO study where ABO was ignored. 

Using ABO identical platelets reduces platelet needs in typical hematologic patients by 50% thus increasing the platelet supply overall.  Prophylactic transfusion at counts <10,000 represent the only evidence based use of platelets, in general.  Prophylactic use prior to paracentesis, colonoscopy, minor surgery, etc. is almost certainly of no benefit in the vast majority of patients,  and leads to harm due to volume effects (250 ml of plasma increases vascular pressure) and inflammation due to the platelets themselves.  References on request.

Edited March 27 by Neil Blumberg

[Neil Blumberg]

For those interested in how bleeding should be treated and bleeding risk assessed, here is a 25 minutes powerpoint lecture on the topic.

 

https://www.vumedi.com/video/evaluation-and-management-of-the-bleeding-patient-and-the-patient-at-risk-of-bleeding/

 

For those who would like further explanation on how we got the benefits and risks of platelet transfusion very wrong, this is a 25 minute YouTube video on the subject.

 

Edited March 27 by Neil Blumberg

[RRay]

Thank you for the information!  Very helpful and will be passed along!