We are seeing an increase number of patient scheduled / emergency for procedures who are on Plavix. Our providers are requesting pheresis platelets on hand for these patients from 1 to 8 or more units. Does anyone have any set protocols that they are using for these patients and their possible platelet needs when scheduled for various procedures, colonoscopy, cardiovascular, AAA, etc. Your comments are greatly appreciated.

Thank you,

Dmr

We are also having quite a problem with this situation. Our physicians don't seem to have any standard protocol, and even though our Hematology Dept offers "Platelet Aggregation" testing, we periodically get "surprise" STAT orders on both emergency and scheduled cases. I, too, would appreciate others' comments/protocol on this topic.

What they really need is an antidote to Plavix.

I would certainly investing in whatever company comes up with a Plavix antidote product!!

Our OR has used TEG testing for the last 4-5 years at our hospital to get an idea of what the total platelet inhibition in all the cases is. Over that time there was a noticeable decrease in the use of FFP, Plts and Cryo. I don't know if any of you are familiar with this testing but it's really cool.

Does anyone know whether transfused platelets actually work if a patient is on plavix?

It doesn't seem to us that it works, because if the patient still has Plavix in their system, it seems to effect the platelets we give. I think we are treating the physician not the patient.

You need to have a test (platelet function assay) which can test for plavix inhibition effects. I believe there is a test called verify now and it tests for Aspirin effect and plavix effect. If the test is abnormal ...I will try to post the website.

http://www.accumetrics.com/products/docs/Waiting_for_Clopidogrel.pdf

Plavix affects the platelets when they are manufactured in the bone marrow. So it should not damage transfused platelets.

Avid -

Thanks for that info - it's good to know that. Can you recommend a good reference (preferably not too complicated) that my staff and I could read to learn more about how & why Plavix works?

Donna

We occasionally give a unit or 2 of platelets to the patient post-op for hip or knee replacement, if there is oozing. The ortho surgeons used to want those plts available preop but have discovered that they rarely need them pre or post. Now they just request platelets on standby at our local blood center's satellite depot. (They are teachable!)

Anesthesia, on the other hand is very nervous and they want 2 units in house. If they are doing a spinal, I don't argue with them, except to suggest we give one and keep the 2nd one at the satellite depot. That has cut our waste rate for plts quite a bit.

Our surgical case load is mostly ortho, gynecological and colon resections, so we don't have nearly as much fun with this as a lot of you do. The cardiologists here are adamant that the patient does not come off Plavis preop, so I'm sure they would veto an antidote, if there was one. Our biggest nightmares are the folks who come in with a GI bleed on Plavix (and the cardiologist won't take them off it). You can suck down a lot of blood in a hurry.

Does anyone know of published guidelines or recommendations for amounts of platelets to give to reverse a plavix effect? We have a physician who insists on having 4-8 pheresis units available for surgery, which we find excessive and difficult.

David, I don't have any references, but I have been trying to find info on this for a couple years. But here's some ideas:

http://www.cbbsweb.org/enf/2001/pltsplavix.html

http://www.cbbsweb.org/enf/1999_2000/reopro.html

http://www.csmc.edu/11261.html

How many do they use?

We encounter this situation most frequently with our open heart surgery patients. We are certain not a "respected leader" in this field, but if our cardiac surgeons give any platelets, it is usually one when they are taking the patient off the pump, and sometimes a second plateletpheresis a few hours later. (We usually don't know which patients are on Plavix.)