Bleeding On Anti-Platelets: A Single Center Quality Assurance Project

Abstract

AbstractAbstract 4708 Background:Treatment of CNS hemorrhage in patients on anti-platelets usually includes transfusion of platelets. Management of bleeding in other sites has not been thoroughly studied. Objective:To identify practice patterns of treatment of hemorrhage in patients on anti-platelets (aspirin and clopidogrel) at a tertiary care hospital within a 3 month period. Methods:This is a retrospective chart review. The Emergency Department provided a list of admitted patients. Target population was identified using the Emergency Department computer system. The patients chart was used in order to extract the following data: age, gender, co-mobridities, medications, baseline and lowest hemoglobin, platelet count, international normalized ratio, partial thromboplastin time and thrombin time, source and type (spontaneous vs trauma) of bleeding, use of packed red blood cells transfused within the first 24 hours, transfusion of platelets; prothrombin complex concentrate; fresh frozen plasma; factor VII; use of desmopressin, surgery or endoscopy within 48 hours from admission. Bleeding was categorized as life threatening, major or minor according to the International Society on Thrombosis and Hemostasis criteria. Statistical analysis was performed with the use of Excel (Microsoft). Results:31 patients with bleeding on anti-platelets were admitted from April 2012 to June 2012. Baseline characteristics and treatment practices are summarized in Table 1. The majority of the bleeds were due to aspirin alone, and anti-platelet agents were discontinued 93% of the time. Most bleeds requiring admission were classified as either life threatening or major. Frequency of packed red cell transfusion in life threatening bleeds was 5/6 (83%), 11/17 (65%) in major bleeds and 2/8 (25%) in minor bleeds. 4 patients were transfused with platelets (one had a CNS bleed), all had the anti-platelets discontinued and they had lower platelet counts compared to non transfused patients [93.2(84) vs 217(80.3), p=0.02]. No patient required desmopressin. All patients who had their anti-platelets continued had minor bleeds. All the bleedings stopped within 48 hours from admission and no deaths secondary to hemorrhagic shock were recorded. Discussion:This is a quality assurance project to assess current physician practices for the management of bleeding in patients on anti-platelet agents. Except for the actual platelet counts, there is no obvious difference between patients transfused with platelets vs non-transfused. At our institutions, anti-platelet related major bleeds are not routinely managed with platelet transfusions. There is a need for additional research to better clarify management. Our study is limited by the fact that it is a retrospective, single institution study. Furthermore, bleeding in inpatients on anti-platelets was not assessed.Table 1Baseline characteristics and treatment practices•Number of bleeding patients/Number of patients seen in ER: 31/3764•Males/Females: 20 (64%)/11 (36%)•Source: Gastrointestinal: 26/31 (84%), Pulmonary: 1/31 (3%), Genitourinary: 3/31 (10%), Central nervous system: 1/31 (3%)•Severity: Life threatening: 6 (19%), Major: 17 (55%), Minor: 8 (26%)•Packed red cell units 1.22 (1.45)-range 0–5•Platelet units[mean (SD)]: Mean: 0.12 (0.34)-range 0–1•Fresh frozen plasma units [mean (SD)]: 0.12 (0.5)-range 0–2•Derivatives: 0•Baseline hemoglobin [mean (SD)]: 10.6 (1.06)-range 10–9.8•Lowest hemoglobin [mean (SD)]: 7.8 (2.38)- range 5–11.6•Platelet counts [mean (SD)]: 200.93 (89.82)-range 12–447 × 103Medication management:•Discontinuation: 29 (93%)•Observation: 2(7%)Procedures:•Endoscopy: 13/31 (42%)•Interventional Radiology: 1/31 (3%)•Surgery: 1(3%) Disclosures:No relevant conflicts of interest to declare.