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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 139-143

An audit of clinical cases of dengue fever and the usage of platelets in such cases in a Tertiary Care Hospital in Hyderabad


1 Department of Pharmacology, Shadan Institute of Medical Sciences, Hyderabad, Telangana, India
2 Department of Transfusion Medicine, Care Hospitals, Hyderabad, Telangana, India

Date of Submission01-Aug-2022
Date of Decision14-Sep-2022
Date of Acceptance26-Sep-2022
Date of Web Publication5-Nov-2022

Correspondence Address:
Bhawani Goru
Department of Pharmacology, Shadan Institute of Medical Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/gjtm.gjtm_60_22

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  Abstract 


Background and Objectives: Dengue is an acute self-limited systemic viral infection caused by the dengue virus of the family Flaviviridae. The incidence of dengue fever has been increasing for the past few years and dengue has become a global problem. The current data required for further improving the treatment policies are scanty. Our study aims to capture the demographic and clinical characteristics of the patients enrolled in the study, to see any correlation between thrombocytopenia and bleeding tendencies and other transfusion-related parameters. Methods: The study is a prospective cohort study. All seropositive dengue cases were included in the study. A format was prepared for documenting the demographic data, history, clinical characteristics, spectrum of the disease, the laboratory details of the patient (platelet count, prothrombin time, activated partial thromboplastin time, Hematocrit, and indication). All the transfusion requirement data were collected from the blood center registers. Overall mortality in the study group, number of hospital readmissions, and episodes of exacerbation of symptoms was recorded separately. Results: A total of 270 cases were included in the audit who fulfilled the inclusion and exclusion criteria. The median age of the patient pool was 27 (4–66 years range). Twenty-six percent of the cases developed hemorrhages. Eighty-four single-donor platelets (SDPs) and 340 random-donor platelets (RDPs) were used. A mean of 270 ml of products was transfused per patient. The mortality rate was 0.8%. The mean duration of hospitalization was 1 week. In 72% of cases, platelet count was restored in single-unit transfusion. Ninety-nine percent of the product utilization were within the guidelines recommended. Conclusion: A good monthly audit of blood product utilization is a good guide for treatment. Quality control and rational use of SDPs and RDPs are important in sick and thrombocytopenic patients resulting in better clinical outcomes.

Keywords: Audit, dengue fever, platelet usage


How to cite this article:
Isharat S, Sharma A, Goru B, Ayatullah Molla M D. An audit of clinical cases of dengue fever and the usage of platelets in such cases in a Tertiary Care Hospital in Hyderabad. Glob J Transfus Med 2022;7:139-43

How to cite this URL:
Isharat S, Sharma A, Goru B, Ayatullah Molla M D. An audit of clinical cases of dengue fever and the usage of platelets in such cases in a Tertiary Care Hospital in Hyderabad. Glob J Transfus Med [serial online] 2022 [cited 2022 Dec 8];7:139-43. Available from: https://www.gjtmonline.com/text.asp?2022/7/2/139/360494




  Introduction Top


Dengue is an acute self-limited systemic viral infection caused by the dengue virus of the family Flaviviridae.[1] The incidence of dengue fever (DF) has been increasing for the past few years and has become a global problem in recent times.[2] According to the WHO, 3.9 billion people are at risk of DF globally.[3] Profound thrombocytopenia is the hallmark of DF.[4] DF with warning signs, severe dengue with plasma leakage, severe bleeding, or organ involvement has emerged as an important public health threat in urban areas. There is a seasonal rise in the number of cases from May to September presenting to emergency and outpatient departments which impose a heavy burden on the staff, laboratories, and blood transfusion units. The risk of severe bleeding is much higher around 2%–4% in patients with a secondary infection.[5]

The current treatment practices differ according to the country and even in different hospitals and teams.[6] Although a lot of advances have been made in transfusion medicine, there still exists some lacunae pertaining to the dosing, quality, storage conditions, and monitoring of transfusion of platelets and its safety.

Our study aims to capture the demographic and clinical characteristics of the patients enrolled in the study, to see any correlation between thrombocytopenia and bleeding tendencies and other transfusion-related parameters, to help the staff and the other allied units in their preparedness, to handle the overburden of the cases during the epidemic season, to maintain the platelet inventory effectively, and to improve our transfusion practices.

Objectives

  1. To capture the clinical data, reports of hematological investigations, and the platelet requirements for a detailed audit
  2. To see whether there is any correlation between the speed of improvement in symptoms with the quality, dose, storage condition of the platelets, and the presence of monitoring staff during transfusion.



  Materials and Methods Top


The study was conducted in a Tertiary Care Hospital in Hyderabad with the help of the Department of General Medicine and Blood Center for 12 months from March 2019 to April 2020.

Ethics

The study was done after taking due permission from the institutional ethics committee.

Type of study

The study is an interventional and prospective cohort study.

Case definitions based on the WHO guidelines were used to diagnose DF and other clinical forms.[7] All seropositive dengue cases were included in the study. The Directorate General of Health Services, Ministry of health and family welfare, and Government of India guidelines were used as a reference for treatment and platelet transfusion [Table 1]. A written notice was circulated to the clinicians/wards/intensive care unit regarding the transfusion protocol and a format was prepared for documenting the demographic data, history, clinical characteristics, spectrum of the disease, and the laboratory details of the patient (platelet count, prothrombin time, activated partial thromboplastin time, Hematocrit, and indication). All the transfusion requirement data were collected from the blood center registers.
Table 1: Guidelines used for platelet transfusion in dengue hemorrhagic fever

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Inclusion criteria

  1. Patients with positive Non-Structural Protein 1 antigen test or dengue antibody serology immunoglobulin M or immunoglobulin G
  2. All pregnant patients and infants irrespective of their platelet counts and confirmed dengue cases were included in the study.


Exclusion criteria

  1. All cases with a different diagnosis of fever
  2. All cases with a different cause for thrombocytopenia
  3. All cases with a different reason for transfusion were excluded from the study.


The relation between the rise in platelet count versus dose as per the yield of the donors (2.5–5.5 × 1011 per unit of single-donor platelet [SDP]), quality (score 4–7), and storage (0–7 days) was established.

Scoring system

Before the platelet transfusion was carried out, 5 ml of the product was taken from the sample pouch and subjected to biochemical analysis. We considered temperature (room temperature = 1; 2°C–6°C = 2), pH (7–4 = 1; <4 = 2), potassium content (3–5 mmol/ml = 1; >5 = 2) of the product, and shape of the platelets (normal = 1; distorted = 2) as quality measurement parameters. A score of 4 was considered a good quality platelet product, whereas a score of >4–7 was considered a compromised quality of platelet product.

The overall mortality in the study group, number of hospital readmissions, and episodes of exacerbation of symptoms were recorded separately.

Statistical analysis

Continuous variables are expressed as mean standard deviation. Paired t-test was performed for data within the groups to see the differences in parameters. Categorical variables are presented as percent values and compared by the Chi-square test. Mann–Whitney and Kruskal–Wallis tests were used for continuous variables like platelet increments or the duration of bleeding. A one-sided P < 0.05 was considered to be statistically significant with a confidence interval of 95%. Further, an effort was made to predict the outcome of the association between the variables with the help of correlation coefficient. Analysis was performed using IBM SPSS Statistics for Windows, Version 23.0.0 Armonk, NY: IBM Corp.


  Results Top


During the study period, a total of 270 diagnosed cases of dengue infection (186 males, 96 females) were admitted and administered platelet transfusions. The median age of patients was 27 (4–66 years range). Age and sex distribution are shown in [Table 2]. Involvement of all age groups was observed. Hemorrhagic manifestations were observed in 69 patients (26%). At presentation, the median platelet count was 26 × 106/L. Eighty-four SDPs were transfused and 340 random-donor platelets (RDPs) were transfused in a total of 186 patients. Ninety-six patients whose platelet count was between 0.2 and 10 × 1011/L received a single unit of platelet transfusion and 46 patients whose platelet count was <0.2 × 1011/L received multiple transfusions. The calculated transfused mean dose was 3 × 1011 platelets/per patient and a range of 220–300 ml of products was transfused.
Table 2: Age distribution of patients audited for the study

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Two patients died during hospitalization (0.8%) mortality due to multiorgan failure secondary to dengue shock syndrome. The rest of the patients recovered completely within 7–8 days of hospitalizations and were discharged. Our audit results showed an overall significant increase in platelet count after transfusion (P < 0.001) except for group 1 where P < 0.05.

Our study specifically found that both males and females responded (rise in platelet count) at par with transfusion (P = 0.716). In 72% of cases, platelets increased significantly in single transfusion itself. The presence of staff proved to be an important factor in reducing the risk of morbidity as transfusion-related adverse drug reactions were reduced (two patients developed allergic reactions such as redness and itching during RDP transfusion) and were immediately taken care of. Our audit showed 30% product utilization within 24 h, 60% within 48 h, and 10% on the 3rd and 4th day which were much within the shelf life of the products and well within the guidelines recommended. Around 14 patients received transfusions on the 5th day of product storage as they were planned for some other interventions in relation to the complications of dengue.

There was a positive correlation between the percentage of platelet increment and dose (+0.736), quality (+0.812), and a negative correlation between the percentage of platelet increment and storage period (−0.695), as shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9].
Figure 1: Scatter plot diagram of dose and platelet rise in count, (r = + 0.736). The dose is 2.2–5.5 × 10 11/unit of the yield of SDP or an equivalent adult dose of RDP. SDP: Single-donor platelet, RDP: Random-donor platelet

Click here to view
Figure 2: Scatter plot diagram of dose and platelet rise in count, (r = + 0.736). The dose is 2.2–5.5 × 10 11 per unit of the yield of SDP or an equivalent adult dose of RDP. SDP: Single-donor platelet, RDP: Random-donor platelet

Click here to view
Figure 3: Scatter plot diagram of dose and platelet rise in count, (r = + 0.736). The dose is 2.2–5.5 × 10 11/unit of the yield of SDP or an equivalent adult dose of RDP. SDP: Single-donor platelet, RDP: Random-donor platelet

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Figure 4: Scatter plot diagram of quality score (4–7) and platelet rise in count (r = + 0.812)

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Figure 5: Scatter plot diagram of quality score (4–7) and platelet rise in count (r = + 0.812)

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Figure 6: Scatter plot of quality score (4–7) and platelet rise in count (r = + 0.812)

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Figure 7: Scatter plot diagram of storage period (0–5 days) and platelet rise in count (r = −0.695)

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Figure 8: Scatter plot diagram of storage period (0–5 days) and platelet rise in count (r =−0.695)

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Figure 9: Scatter plot diagram of storage period (0–5 days) and platelet rise in count (r = −0.695)

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  Discussion Top


Dengue is now endemic in India, sparing neither region nor any age group.[8] Its clinical ill effects are most obvious on a large scale with the onset of the monsoon season and lasts till the advent of winter. The more rainfall leads to waterlogging and overwhelming the sewage management capacity, the more the breeding spots for mosquitoes lead to more number of cases. In our study, the percentage of the male population affected was more than double compared to the female population, owing to the higher mobility of males outside the confines of homes for jobs. The significantly low platelet counts at admission (26 × 109/L) and the higher percentage of hemorrhagic manifestations (26%) as compared to some other studies may be due to the referral of sick patients from the periphery to the tertiary hospitals due to worsening of symptoms after 2 to 3 days of primary care. None of the guidelines recommend prophylactic transfusion or guidelines recommend platelet transfusions only when it drops to 5 × 109/L – the WHO guidelines.[7] However, it is a standard practice across most countries to transfuse platelets prophylactically when the platelet drops below 10–20 × 109/L. In our study, 46 patients (about 32.3% of all transfused cases) had platelet counts below 20 × 109/L and accounted for all of the 30% of the SDPs which were issued immediately after the procedure (within 24 h) reflecting the emergency of clinicians. They additionally received RDPs and other blood components as well. The remaining patients below 20 × 109/L counts were transfused only RDPs. The main reasons in our study for RDP transfusions versus SDPs in certain patients were as follows:

  1. Patients from out of city/state, who had no known family/donors in the city
  2. High cost of SDP versus RDPs and unaffordable patients.


Ninety-six patients (67.6%) received transfusions although their platelet count was between 20 and 100 × 109/L. They also accounted for all of the SDPs issued after 24 h and the maximum of the RPDs issued.

The main reasons in our study for transfusions above 20 × 109/L were as follows:

  1. The presence of petechial rashes and hemorrhagic manifestation clinically justify transfusion
  2. Planned invasive procedures (neurological) which accounted for the 10% transfusions of SDPs on days 3 and 4 after collection
  3. Panic by patient attendants/family and transfusions by clinicians under family pressure.


According to most standards of blood component transfusions, a single SDP raises the platelet count in the recipient by 20–50 × 109/L and a single RDP by about 3–5 × 109/L, in a relatively stable patient.[9] The satisfactory quality control data, yield, and volume of the platelet components in our study also collaborate with the above standards and resulted in maximum patients (about 72%) showing a significant increase in platelet count only after a single unit of SDP transfusion.[10]

Thus, quality control and rational use of SDPs and RDPs are important in sick and thrombocytopenic dengue patients resulting in better clinical outcomes when used in appropriate cases.


  Conclusion Top


The above study results will contribute to the existing literature and data about DF pertaining, especially in the Indian population. It will also help in formulating more precise strategies and guidelines for handling patients suffering from dengue infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gubler DJ. The global emergence/resurgence of arboviral diseases as public health problems. Arch Med Res 2002;33:330-42.  Back to cited text no. 1
    
2.
Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 2
    
3.
Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Hoen AG, et al. Refining the global spatial limits of dengue virus transmission by evidence-based consensus. PLoS Negl Trop Dis 2012;6:e1760.  Back to cited text no. 3
    
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Simmons CP, Farrar JJ, Nguyen VV, Wills B. Dengue. N Engl J Med 2012;366:1423-32.  Back to cited text no. 4
    
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Amin P, Acicbe Ö, Hidalgo J, Jiménez JI, Baker T, Richards GA. Dengue fever: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2018;43:346-51.  Back to cited text no. 5
    
6.
Guzmán MG, Kourí G. Dengue: An update. Lancet Infect Dis 2002;2:33-42.  Back to cited text no. 6
    
7.
WHO. Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Hemorrhagic Fever. Revised and Expanded Editing. World Health Organization, Regional Office for South-East Asia; 2011.  Back to cited text no. 7
    
8.
Murhekar M, Joshua V, Kanagasabai K, Shete V, Ravi M, Ramachandran R, et al. Epidemiology of dengue fever in India, based on laboratory surveillance data, 2014-2017. Int J Infect Dis 2019;84S: S10-4.  Back to cited text no. 8
    
9.
Khan Assir MZ, Kamran U, Ahmad HI, Bashir S, Mansoor H, Anees SB, et al. Effectiveness of platelet transfusion in dengue fever: A randomized controlled trial. Transfus Med Hemother 2013;40:362-8.  Back to cited text no. 9
    
10.
Kansay S, Singh H. Effect of introduction of single-donor apheresis platelets in dengue management: A comparative analysis of two consecutive dengue epidemics. J Lab Physicians 2018;10:173-8.  Back to cited text no. 10
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