title: Platelet transfusion and catheter insertion for plasma exchange in patients with thrombotic thrombocytopenic purpura and a low platelet count.
abstract: BACKGROUND
  In thrombotic thrombocytopenic purpura (TTP), platelet (PLT) transfusion is contraindicated unless a life-threatening hemorrhage occurs. However, when PLT count is low (<20 × 10(9) /L), their benefit-risk balance before central venous catheter (CVC) insertion for plasma exchange (PE) has not specifically been addressed in guidelines.
  
  
  METHODS
  We report two cases in which PLTs were transfused before CVC insertion for PE, resulting in fatal myocardial infarction or neurologic complications.
  
  
  CONCLUSIONS
  To date, there is a paucity of high-quality, evidence-based information on prophylactic PLT transfusion for CVC placement in TTP. Several monocenter series report that CVC could be inserted safely without PLT transfusion by experienced teams under ultrasound guidance. Uncertainty makes most physicians uncomfortable with this decision and this is a common reason why PLT transfusion remains a "precautionary" albeit misguided position.
  
  
  CONCLUSIONS
  We propose a practical algorithm to avoid unnecessary PLT transfusion before CVC insertion for rapid PE in the initial management of TTP patients. We recommend no prophylactic PLT transfusion but CVC insertion in a compressible vein under ultrasound guidance by an experienced team or quick PE started on two peripheral veins if possible. PLTs should only be transfused in case of severe bleeding in association with plasma infusion and CVC insertion for immediate PE.
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.|INSERM U 1034, Bordeaux, France.
authors.forename: Etienne
authors.identifier: http://orcid.org/0000-0003-0254-3394
authors.initials: E
authors.lastname: Riviere
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.
authors.forename: Mélanie
authors.initials: M
authors.lastname: Saint-Léger
authors.affiliation: Laboratory of Hematology, Haut-Leveque Hospital, Bordeaux, France.|INSERM U 1034, Bordeaux, France.
authors.forename: Chloé
authors.initials: C
authors.lastname: James
authors.affiliation: Nephrology and Dialysis Department.|French Reference Center for Thrombotic Microangiopathies, AP-HP, Saint-Antoine Hospital, Paris, France.
authors.forename: Yahsou
authors.initials: Y
authors.lastname: Delmas
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Clouzeau
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.
authors.forename: Nam
authors.initials: N
authors.lastname: Bui
authors.affiliation: Pathology Department, Pellegrin Hospital, Bordeaux, France.
authors.forename: Anne
authors.initials: A
authors.lastname: Vital
authors.affiliation: Hematology Department, UPMC Paris-6 University, Paris, France.|French Reference Center for Thrombotic Microangiopathies, AP-HP, Saint-Antoine Hospital, Paris, France.
authors.forename: Paul
authors.initials: P
authors.lastname: Coppo
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.|French Reference Center for Thrombotic Microangiopathies, AP-HP, Saint-Antoine Hospital, Paris, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Gruson
authors.affiliation: Medical Intensive Care Unit, Bordeaux, France.|INSERM U 657, Bordeaux Segalen University, Bordeaux, France.|French Reference Center for Thrombotic Microangiopathies, AP-HP, Saint-Antoine Hospital, Paris, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Boyer
mesh_terms: D000328:Adult; D000368:Aged; D002405:Catheterization, Central Venous; D005260:Female; D006801:Humans; D008297:Male; D010951:Plasma Exchange; D010976:Platelet Count; D017713:Platelet Transfusion / Q000379:methods*; D011697:Purpura, Thrombotic Thrombocytopenic / Q000097:blood* / Q000473:pathology / Q000628:therapy*