Low Platelet Count

[RNScott]

I had a 16 year old patient recently who was the victim of a GSW to the L groin. It lacerated his L femoral artery. The artery was repaired with a graft. I received him in the ICU and he developed compartment syndrome in his abdomen and L thigh. He ended up with an open abdomen and thigh with wound vacs in place. A couple days later his kidneys failed and he ended up on CRRT. His leg was dying although he had a good pulse in it. They did an AKA. He was still in critical condition when I left with high lactate and still on CRRT. The plan was to do a disarticulation in a few days. He had an extremely low platelet count, which bottomed out at 5,000 the morning of the AKA and he was given around 6- 6 packs of platelets to get his count up to 63,000 so he could go to surgery. By that night his count was back at 13,000 and when given a 6 pack went up to 25,000. No one could really figure out why his platelet count was so low and kept dropping down. This had gone on for several days of dropping and then getting platelets and coming up to about 20-30 and then right back down under 15,000. Some said that CRRT will chew up platelets but I have had other patients on CRRT that that was not a problem. Just wondering if anyone has any ideas why such a low platelet count that just kept dropping down even when given platelets.

[detroitdano]

Maybe he had DIC?

[RNScott]

That was discussed in the beginning because his coags were off but they had normalized and this was still happening with his platelets.

[WalkieTalkie, RN]

Did he receive heparin at all for the CRRT or for any other reason?

[RNScott]

No. He never received Heparin. Thanks for all the replies.

[dianah, ASN]

http://www.medicinenet.com/thrombocytopenia_low_platelet_count/page2.htm

Could be many causes (see above).

[NurseKitten, MSN, RN]

I've seen CRRT chew up red cells in the past...have you considered asking one of the inpatient dialysis nurses to come evaluate things that can cause cellular lysing through mechanical means via the CRRT?

If you have ruled out biochemical means, then start looking at the machine itself. Do you have a hard time "pulling"? Are the pump wheels for the machine correctly calibrate for the type tubing you're using? What are his other hematology studies looking like - specifically the red cells? (But they're gonna be a low anyway, because he IS in renal failure and inflammed as heck, plus the normal hemolysis that comes as part of the CRRT process.)

There are too many factors to list out here, but an experienced inpatient hemodialysis nurse can just about look at it and tell you if that could be part of it.

Good luck to you and this unfortunate young man.

[caroladybelle, BSN, RN]

As he had a GSW, did he perhaps have received large amounts of platelets previously in his treatment or at any prior time in his life? And were the platelets that he was receiving "single donor/pheresis" or "random donor"?

In hematology, our leukemics in Induction therapy will be transfused with multiple units of platelets because of extended bone marrow suppression. Some of them become "platelet refractory"....they either do not increment well or will actually drop their platelet counts after transfusion. Their bodies have become so sensitized to platelets, that they destroy them faster.

In hematology, we routinely limit platelet transfusions to counts of 10,000 or less, 20,000 if febrile or minimal bleeding. For procedures we try to get them to 50,000 but that is not always possible. But of course these parameters would probably not work for a postop pt.

Other options for prevention: premedding for platelet transfusions, using single donor/pheresis platelets, using irradiated, leukoreduced platelets...but again this is more prevention, and does not help as much if the pt is already sensitized.

For seriously platelet refractory pts, we use HLA matched (more closely matched) platelets, though these can be harder to come by. And in a few pts, when we are able, we have gotten pheresis units from a matched family member (rarely an option).

Fevers can also decrease platelet counts. As can DIC.

I would also consider the CRRT as a possibility.

[caroladybelle, BSN, RN]

Okay, I saw the 6-6-packs platelets, so he got random donor platelets and not pheresis single donor)

(We NEVER give random donor platelet to our leukemias - they used to always get refractory. Using single donor pheresis helps prevent that in our people)

Have they tried single donor pheresis platelets or HLA matched platelets?

(And has he gotten a lot of random donor platelets in the past)

[RNScott]

He was getting random donor platelets.

[gcj95]

Very interesting, and unfortunate. I had a similar problem this week. My patient however was an elderly patient that was put on CRRT (CVVH) for ARF. She too experienced a drop in her platelet count from about 150,000 to about 15,0000 she also had an developed an INR of 4.5, a PTT of about 45 and a fibrinogen of about 85.

Her coagulopathy did reverse after many blood products, however the cause remains a mystery. Thanks for sharing your story

Greg

[NurseKitten, MSN, RN]

Not uncommon in either ARF or CRRT (for any etiology) for some weird, unexplained coagulopathies to come into play. Have seen it many times...