When I started work as a doctor, dengue was not as common as it is today, and it was alarming to watch the platelet counts crash during the course of the infection. Senior hospitalists would routinely leave standing orders for platelet transfusions, usually once the platelet count of the patients had fallen below some arbitrary figure that ranged from 20-50 cells/cubic millimetre (the lower end of the normal range is usually around 140 cells/cubic millimetre). Such transfusions were prophylactic in nature – “just in case the patient bleeds”; there may even have been some that believed that low platelet counts were associated with higher risks of bleeding, or that the transfusions were partially therapeutic (most patients generally looked and felt better after the transfusions).
This conventional wisdom started being challenged over time, and by the time I started training in infectious diseases, we understood that such transfusions may not be beneficial at all. Certainly there were downsides – besides the increased healthcare cost, there was a small risk of transfusion reactions. But there were (and still are) holdouts who believed otherwise – generally older generation physicians and younger physicians who had not shaken off their traditional training and experiences. At the end of the day, there was no high quality clinical evidence to support or reject either clinical practice.
Thus it is good that there is finally a robust clinical trial that settles the issue – demonstrating that platelet transfusions conveyed no benefits compared to routine supportive care, and incurred a higher risk of adverse events related to the transfusion. It is even better that this study was conceived and funded in Singapore, performed in several local as well as Malaysian hospitals. And the study team deserves the highest accolades for publishing this work in the Lancet (behind a pay wall).
Screen capture from Todayonline reporting on the dengue platelet transfusion study
But I also understand from experience that it takes time and effort before best practices are adopted by clinicians. The follow up article in the Straits Times today
was perhaps inadvertently revealing (or just demonstrated that SGH was in this instance somewhat less PR-savvy than NUH).
Screen capture from the Straits Times article on the dengue platelet transfusion study.