Guideline Summary NGC-9178

Guideline Title Platelet and plasma transfusion policy. In: Blood transfusion guideline. Bibliographic Source(s) Platelet and plasma transfusion policy. In: Blood transfusion guideline. Utrecht (The Netherlands): Dutch Institute for Healthcare Improvement CBO; 2011. p. 209-77. [291 references] Guideline Status This is the current release of the guideline.

Scope
Disease/Condition(s) Thrombocytopenia or thrombocytopathy Guideline Category Evaluation Management Prevention Risk Assessment Treatment Clinical Specialty Critical Care Emergency Medicine Family Practice Gastroenterology Hematology Internal Medicine Neurological Surgery Nursing Obstetrics and Gynecology Oncology Orthopedic Surgery Pediatrics Preventive Medicine Rheumatology Surgery Thoracic Surgery Intended Users Advanced Practice Nurses Hospitals Nurses

Surgery Thoracic Surgery Intended Users Advanced Practice Nurses Hospitals Nurses Pharmacists Physician Assistants Physicians Public Health Departments Guideline Objective(s)
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Tocreateamulti-disciplinary guideline on transfusion policy of blood and blood components Tostimulateamoreuniformclinicalthinkingandactinginthefieldofbloodtransfusion Toconfirmtheroleofnursesinbloodtransfusions

Toincorporatenewnationalinitiatives such as the creation of the Transfusion Register for Irregular antibodies and X match problems (TRIX) database for irregular red cell antibodies Toclinicallyevaluatetransfusionandtheclinicaltransfusionresearchtosupportthebasisforguidelinedevelopment and skills improvement of employees involved in blood transfusion, with a focus on the hospital situation
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Target Population Patients of all ages in the Netherlands who might require platelet or plasma transfusions, either in the hospital or outside the hospital, for example in the independent treatment centres (ITC) and via home care organisations Interventions and Practices Considered 1.Indicationforplatelettransfusioninspecificneonatepopulations
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Foetal/neonatalallo-immune thrombocytopenia Neonateswhenmotherhasanauto-immune thrombocytopaenic purpura (ITP) Congenitalthrombocytopeniaandthrombocytopathyinchildren Childrenwiththrombocytopeniaduetoleukaemia Severeaplasticanaemia(SAA)inchildren Acceleratedbreakdownorconsumptioninchildren Childrenundergoinginvasiveprocedures Congenitalthrombocytopenia/thrombocytopathy Acquiredproductiondisorders Peripheralthrombocytopeniaduetoantibodies

2.Indicationforplatelettransfusioninspecificchildpopulations
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3.Indicationforplatelettransfusioninspecificadultpopulations
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Thrombocytopeniaduetoantibodiesconsumptioninthromboticthrombocytopaenicpurpura(TTP),haemolytic uraemic syndrome (HUS), haemolysis elevated liver enzymes and low platelets (HELLP), disseminated intravascular coagulopathy (DIC) and heparin-induced thrombocytopenia (and thrombosis) (HIT[T])
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Plateletlossduetopoolinginsplenomegaly Acquiredthrombocytopathy Selectionofhumanleukocyteantigen(HLA)andhumanplateletantigen(HPA)compatibledonors

4.Platelettransfusionpractices
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Supportingtreatmentsfortherapy-resistant bleeding: erythrocyte transfusion, inhibition of fibrinolysis and recombinant factor VIIa (rFVIIa) erythrocyte transfusions
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Determinationofdosageandvolumeofplatelettransfusioninneonates,childrenandadults

Major Outcomes Considered

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Mortality Complicationratesfromplasmaorplateletinfusions Rateofchangeinplateletcount Changeintransfusionrequirement Rateoftransfusionfailure(refractoriness)

Methodology
Methods Used to Collect/Select the Evidence Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases

Rateoftransfusionfailure(refractoriness)

Methodology
Methods Used to Collect/Select the Evidence Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases Description of Methods Used to Collect/Select the Evidence Relevant articles were found by performing systematic search actions in the Cochrane Library, Medline and EMBASE. The languages were limited to Dutch, English, German and French. Manual searches were also performed. The search was performed from 2003 (Medline) and for some questions also in EMBASE or CINAHL up to and including February 2008. After the literature search, the result was evaluated by the working group members and the articles were evaluated for clinical relevance. If there was a possibility that the initial question could be answered with the article, the article was included in the selection. Number of Source Documents Not stated Methods Used to Assess the Quality and Strength of the Evidence Expert Consensus Weighting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence Categorisation of Methodological Quality of Individual Studies
Intervention Diagnostic Accuracy of Research Damage or Adverse Effects, Etiology, Prognosis*

A1 A2

Systematic review of at least two studies performed independently of each other at level A2 Randomised, double-blind, comparative clinical study of good quality and sufficient size Research with respect to a reference test (a 'golden standard'), with previously defined limits and independent evaluation of the results of test and gold standard, concerning a sufficiently large series of consecutive patients who have only had the index test and reference test Prospective cohort study of sufficient size and follow-up, with adequate checks for 'confounding' and sufficient exclusion of selective follow-up. Prospective cohort study, but not including all characteristics as mentioned under A2 or a retrospective cohort study or patient-control study

Comparative study, but not with all Study compared to a reference test, but not including all the the characteristics as mentioned characteristics mentioned under A2 under A2 (these also include patientcontrol study, cohort study) Non-comparative study Expert opinion

C D

*This classification only applies in situations where controlled trials are not possible due to ethical or other reasons. If these are possible, then the classification for interventions applies. Methods Used to Analyze the Evidence Review of Published Meta-Analyses Systematic Review with Evidence Tables Description of the Methods Used to Analyze the Evidence The guidelines and reviews that were found were evaluated for quality by the chairmen with the aid of the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Methods Used to Formulate the Recommendations Expert Consensus Description of Methods Used to Formulate the Recommendations Composition of the Core Group and Working Group The blood transfusion policy guideline working group had a multi-disciplinary composition: as many professionals as possible from various disciplines involved in blood transfusion were asked to participate. In composing the working group, a balanced representation was sought of the various disciplines involved, the geographical distribution of the members and the proportion of academic to non-academic institutions. Members of the working group were invited to take part in the working group via the relevant (scientific) associations based on their personal expertise and/or affinity with the subject. They did not receive any payment and/or reimbursement of travel costs for their presence at working group meetings. A small core group was formed from the members of the working group. The working group was chaired by two chairmen, who also acted as chairmen for the core group. The working group members and core group members acted independently and were mandated by their association for participation in the working group. Working Method for Guideline Development The revision started with an inventory of the bottlenecks observed in practice with the Blood Transfusion guideline from 2004, which served as a starting point for the revision. The working group members were asked to consult their association members to name and create an inventory of these bottlenecks. The relevant patient groups (see also under 'Patient perspective' in the original guideline document) were also asked to name and create an inventory of the bottlenecks that they experience in the practical situation. Once the bottlenecks had been collected, they were categorised in the relevant chapter. Seven initial questions were distilled from the prioritised bottlenecks for elaboration by a Centraal BegeleidingsOrgaan (CBO) advisor. Core Group Working Method

independently and were mandated by their association for participation in the working group. Working Method for Guideline Development The revision started with an inventory of the bottlenecks observed in practice with the Blood Transfusion guideline from 2004, which served as a starting point for the revision. The working group members were asked to consult their association members to name and create an inventory of these bottlenecks. The relevant patient groups (see also under 'Patient perspective' in the original guideline document) were also asked to name and create an inventory of the bottlenecks that they experience in the practical situation. Once the bottlenecks had been collected, they were categorised in the relevant chapter. Seven initial questions were distilled from the prioritised bottlenecks for elaboration by a Centraal BegeleidingsOrgaan (CBO) advisor. Core Group Working Method The primary task of the core group was to monitor the progress of the entire process, including the results of the working group. The core group members were each responsible for the end result of one or more chapters. The core group also collaborated with the CBO in the final editing of the guideline. Working Group Working Method The working group worked on the creation of a draft guideline over a period of two and a half years. The entire working group met on several occasions for plenary discussion, development and approval of the draft texts. The working group worked in small sub-groups outside the plenary meetings on the revision of chapters for the guideline. Some working group members were involved in the revision of several chapters. For each chapter, one working group member was responsible for the revision of the chapter, supported by the core group member(s) with ultimate responsibility. The CBO information specialist wrote the draft evidence text. These draft evidence texts were then evaluated by the relevant sub-working groups and supplemented with other considerations from the practical setting and recommendations based on the conclusions from the scientific literature and these other considerations. All draft texts were discussed several times in the plenary working group, commented on and eventually approved. Texts developed by the working group were then edited by the core group and the CBO to form the draft guideline. Prof. W.G. van Aken, internist n.p., read the draft texts in the final phase critically and made suggestions for improvement. Where there continued to be a lack of evidence based knowledge on certain subjects despite new literature, the working group based on discussion and consensus formulated suggestions and recommendations. Other Considerations In order to make a recommendation, in addition to scientific proof, there were also other important aspects such as patient perspective, organisational aspects and costs. Rating Scheme for the Strength of the Recommendations
1 2 3 4 Level of Conclusions

Research of level A1 or at least 2 studies performed independently at level A2, with consistent results 1 study of level A2 or at least 2 studies performed independently at level B 1 study at level B or C Expert opinion

See the 'Rating Scheme for the Strength of the Evidence' field for definitions of levels A1-C. Cost Analysis Cost-efficacy data are available in the original Dutch language guideline. Method of Guideline Validation External Peer Review Internal Peer Review Description of Method of Guideline Validation The draft guideline, which could be consulted via the Centraal BegeleidingsOrgaan (CBO) website, was submitted to the relevant associations with mandated representatives in the working group for a consultation round (see the original guideline document for mandating organisations). The relevant groups listed under 'Patient perspective' in the original guideline document were also specifically asked to comment on the Blood Transfusion draft guideline. The resulting comments were processed in the definitive draft guideline. Following inclusion of the comments, the draft guideline was submitted to the associations for authorisation and it was approved on 1 August 2011.

Recommendations
Major Recommendations Note from the Dutch Institute for Healthcare Improvement Centraal BegeleidingsOrgaan (CBO) (DIHG) and the National Guideline Clearinghouse (NGC): The Blood Transfusion Guideline has been divided into individual summaries covering blood components, laboratory aspects, chronic and acute anemia, platelet and plasma transfusions, side effects, and techniques to save blood. In addition to the current summary, the following are available:
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Blood components: characteristics, indications, logistics and administration Laboratory aspects Chronic anaemia Transfusion policy for acute anaemia Transfusion reactions and related conditions Blood saving techniques and medications

Transfusion Policy in Thrombocytopenia and Thrombocytopathy Indications for Platelet Transfusion in Thrombocytopenia and Thrombocytopathy When balancing the indication for a platelet transfusion, the aim of the transfusion must be compared to the cause of the thrombocytopenia or thrombocytopathy. Prevention of spontaneous bleeding, prevention of bleeding during procedures or treatment of manifest (severe) bleeding grade >2 are possible aims of platelet transfusions in thrombocytopenia or

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Chronic anaemia Transfusion policy for acute anaemia Transfusion reactions and related conditions Blood saving techniques and medications

Transfusion Policy in Thrombocytopenia and Thrombocytopathy Indications for Platelet Transfusion in Thrombocytopenia and Thrombocytopathy When balancing the indication for a platelet transfusion, the aim of the transfusion must be compared to the cause of the thrombocytopenia or thrombocytopathy. Prevention of spontaneous bleeding, prevention of bleeding during procedures or treatment of manifest (severe) bleeding grade >2 are possible aims of platelet transfusions in thrombocytopenia or thrombocytopathy. The working group recommends that the indication definition according to the table 'Indications for Platelet Transfusions in Thrombocytopenia and/or Thrombocytopathy' below is used as a guideline. Table: Indications for Platelet Transfusions in Thrombocytopenia and/or Thrombocytopathy (see recommendation under 'Indications for Transfusion in Neonates' and the table 'Literature Summary of Prophylactic Transfusion Triggers in Adults with Thrombocytopenia Due to a Production Disorder' in the original guideline document for triggers)
Acquired Thrombocytopenia +/ - Thrombocytopathy Caused by: Congenital Thrombocytopathy Haemodilution Production Disorder Splenomegaly Breakdown/Use

Prevention spontaneous bleeding Yes Prevention during procedures Bleeding grade >2 Yes Yes

Yes Yes* Yes

Consider Yes Yes

No Possibility Yes

No Possibility* Yes

*Unless contra-indicated (see the 'Contraindications' field) Platelet Transfusion Policy in Neonates Indications for Transfusion in Neonates Table: Platelet Threshold Values as Indication for Platelet Transfusion in Neonates During the First Month of Life
Patient Groups Platelet Transfusion Trigger

Birth Weight <1,500 g and <32 Weeks Stable Sick Manifest bleeding/procedure BirthWeight1,500gor32Weeks Sick or not sick Manifest bleeding/procedure Special Circumstances Exchange transfusion (ET)*, before ET During extra-corporeal membrane oxygenation
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20 x 10 9 /L 50 x 10 9 /L 50 x 10 9 /L 20 x 10 9 /L 50 x 10 9 /L 100 x 10 9 /L 100 x 10 9 /L

*If the platelet count is <100 x 10 /L before the ET, then give platelet transfusion half-way through the ET. If the platelet count is <50 x 10 9 /L after the ET, then also give a platelet transfusion.

Platelet Transfusion Policy for Foetal/Neonatal Allo-Immune Thrombocytopenia (FNAIT) 1.InthetreatmentofFNAIT,adistinctionshouldbemadebetweenaneonatewithunexpectedthrombocytopenia and a pregnancy after a previous child with thrombocytopenia due to FNAIT. 2.DiagnostictestsforFNAITshouldbestartedifafulltermneonatehasthrombocytopeniawithoutindicationsfor congenital abnormalities, infections, allo-immune haemolytic disease or auto-immune thrombocytopaenic purpura (ITP) in the mother. If there is a bleeding tendency, the neonate should be transfused according to the table 'Platelet Threshold Values as Indication for Platelet Transfusion in Neonates During the First Month of Life' above. Human platelet antigen (HPA) compatible platelets should preferably be given (in other words, HPA negative for the antigen against which the antibody is targeted). 3.IfHPAcompatibleplateletsarenotimmediatelyavailable,randomtransfusionsarenotcontra-indicated whilst awaiting HPA compatible transfusions. 4.InanelectivedeliveryofachildwithFNAIT,HPAcompatibleplatelettransfusionsconcentratesshouldbe available immediately. 5.FNAITispreferablytreatednon-invasively (with intra-uterine transfusions) during the pregnancy. 6.ItisrecommendedthatdoctorscontacttheLeidenUniversityMedicalCentre the national centre for foetalmaternal allo-immune diseases for advice about treatment options for FNAIT. Platelet Transfusion Policy in Neonates if the Mother Has an ITP 1.IfthemotherhasahistoryofITP,theaimshouldbetohaveanon-traumatic birth, as far as possible. 2.InaneonateborntoamotherwithIPT,theplateletcountshouldbecheckedforatleast5dayspost-partum to check for the occurrence of thrombocytopenia. 3.Intravenousimmunoglobulin(IVIG)isrecommendedasthetreatmentofchoiceforneonateswithpassive idiopathic ITP and platelet count <50 x 10 9/L without clinical bleeding; to be combined with (methyl) prednisolone in the case of persistent thrombocytopenia. 4.Plateletstransfusion alone or in combination with IVIG is recommended for neonates with passive IPT and <20 x 10 9/L platelets and/or bleeding. Dosage and Volume of Platelet Transfusions in Neonates 1. Itisrecommendedtoadministerplateletstoneonatesatadosageofatleast10x10 9/kg body weight. 2.Foraplatelettransfusioninneonates,theplateletcomponentfortransfusionshouldbeobtainedfromonedonor. 3.Furtherresearchisessential,forexampleontheoptimumdosageand/orthevariousplateletcomponentsinthe platelet transfusion policy in neonates. Platelet Transfusion Policy for Thrombocytopenia and Thrombocytopathy in Children (>1 Month After Full Term Birth) Platelet Transfusion Policy in the Case of Congenital Thrombocytopenia and Thrombocytopathy in Children 1.Inthecaseofcongenitalthrombocytopeniaandthrombocytopathy,itisadvisabletolimittheadministrationof

1. Itisrecommendedtoadministerplateletstoneonatesatadosageofatleast10x10 9/kg body weight. 2.Foraplatelettransfusioninneonates,theplateletcomponentfortransfusionshouldbeobtainedfromonedonor. 3.Furtherresearchisessential,forexampleontheoptimumdosageand/orthevariousplateletcomponentsinthe platelet transfusion policy in neonates. Platelet Transfusion Policy for Thrombocytopenia and Thrombocytopathy in Children (>1 Month After Full Term Birth) Platelet Transfusion Policy in the Case of Congenital Thrombocytopenia and Thrombocytopathy in Children 1.Inthecaseofcongenitalthrombocytopeniaandthrombocytopathy,itisadvisabletolimittheadministrationof platelet transfusions because of the development of alloantibodies. 2.Inthecaseofcongenitalthrombocytopeniaandthrombocytopathy,platelettransfusionsareonlyindicatedinthe case of severe bleeding and if other treatment options for the relevant condition are not effective. Children with Thrombocytopenia Due to Leukaemia (Treatment) 1.Forchildreninastablesituationwithleukaemiabeingtreatedwithhighdosechemotherapyorafterstemcell transplantation, the working group advises a prophylactic platelet transfusion trigger of 10 x 10 9/L. 2.Inchildrenwithleukaemia,beingtreatedwithhighdosechemotherapyorafterstemcelltransplantationandwith an increased risk of bleeding due to platelet use as is the case of sepsis, hyperleukocytosis, a very rapid drop in platelet count or other abnormalities in haemostasis a platelet transfusion trigger of 20 x 10 9/L is advised. Platelet Transfusion Policy for Severe Aplastic Anaemia (SAA) in Children 1.InstablechildrenwithSAA,itisrecommendedtomaintainarestrictiveprophylacticplatelettransfusionpolicyand maintain a trigger of for example 5 x 10 9/L. 2. InchildrenwithSAAandinfections,feverorsepsis,aplatelettransfusiontriggerof10x10 9/L is advised for prophylactic platelet transfusions. 3.Inchildrenbeingtreatedwithanti-thymocyte globulin (ATG), prophylactic platelet transfusions are advised at a platelet transfusion trigger of 20 x 10 9/L. Platelet Transfusion Policy for Thrombocytopenia Due to Accelerated Breakdown or Consumption in Children 1.ForthrombocytopeniaduetoincreasedbreakdownorconsumptioninthecaseofITP,disseminatedintravascular coagulation (DIC), thrombotic thrombocytopaenic purpura (TTP), haemolytic-uraemic syndrome (HUS) or heparininduced thrombocytopenia (and thrombosis) (HIT[T]), the transfusion of platelets is only indicated for life threatening bleedings. 2.ForlifethreateningbleedingsinthecaseofITP,theadviceistoadministerplatelettransfusionsincombination with IVIG. 3.ForchildrenwiththrombocytopeniaduetoDIC,onecanconsiderprophylacticplatelettransfusionsataplatelet trigger of 20 x 10 9/L. Platelet Transfusion Policy for Thrombocytopenia Due to Invasive Procedures in Children There is insufficient literature available concerning the platelet transfusion policy for invasive procedures and surgical procedures other than lumbar punctures (LPs) in children with thrombocytopenia. Therefore, the working group advises that, for the time being, the recommendations for adults should be followed for such procedures (see 'Platelet Transfusion Policy in Adults' below). Platelet Transfusion Policy for an LP in the Presence of Thrombocytopenia 1. Aplateletcountof>50x10 9/L is recommended for an LP in children with acute lymphatic leukaemia (ALL) with blasts in the peripheral blood. 2.InstablechildrenwithALL,withoutblastsintheperipheralblood,anLPcanbeperformedsafelyataplatelet count of >10 x 10 9/L. 3.Ahigherplatelettransfusiontriggershouldbeconsideredifgeneralanaesthesiacannotbeusedonachild undergoing an LP and/or if the physician who performs the LP is inexperienced. Please refer to the guideline 'PSA for children in locations outside the OR' (NVA [Nederlandse Vereniging voor Anesthesiologie (Dutch Society of Anesthesiology)], NVK [Nederlandse Vereniging voor Kindergeneeskunde (Dutch Society of Pediatrics)], 2010) for the accessory conditions concerning the use of anaesthesia and/or procedural sedation and/or analgesia (PSA) when performing an LP. Dosage of Platelets in Children The old dosage advice for platelet transfusion in children namely one paediatric unit of 50 to 100 x 10 9/10 kg (= 510 x 109/kg) is maintained. Platelet Transfusion Policy in Adults Platelet Transfusion Policy for Congenital Thrombocytopenia/Thrombocytopathy 1.Forpatientswithacongenitalthrombocytopathyand/orthrombocytopeniatheadviceistolimittheadministration of platelet transfusions as much as possible due to the development of alloantibodies, which can destroy the effect of platelet transfusions. 2.Prophylacticplatelettransfusionsarenotindicatedincaseofcongenitalthrombocytopeniaandthrombocytopathy. 3.Incongenitalthrombocytopeniaandthrombocytopathyplatelettransfusionsareindicatedforproceduresandin case of severe bleeding if other treatment modalities are not effective. Platelet Transfusion Policy for Thrombocytopenia Due to Acquired Production Disorders Platelet Transfusions for the Prevention of Spontaneous Bleeding Versus Therapeutic Transfusions Prophylactic platelet transfusions are recommended for patients with thrombocytopenia due to an acquired production disorder. A therapeutic transfusion policy may be considered for otherwise healthy patients experiencing a short period of pancytopaenia. The Platelet Transfusion Trigger for Prophylactic Platelet Transfusions for the Prevention of Spontaneous Haemorrhage 1. Inthecaseofastandardriskofbleeding,atransfusiontriggerof10x10 9/L is recommended for prophylactic platelet transfusions. 2.Ifthereareadditionalclinicalcomplicationsthatpromotebleeding,itisrecommendedthattheplatelet transfusion trigger be increased to 20 x 10 9/L for prophylactic platelet transfusions. 3.Forpatientswithanindicationforanti-coagulant treatment, it is recommended to increase the platelet transfusion trigger to 50 x 10 9/L in order to prevent spontaneous bleeding; this is not evidence based.

Platelet Transfusions for the Prevention of Spontaneous Bleeding Versus Therapeutic Transfusions Prophylactic platelet transfusions are recommended for patients with thrombocytopenia due to an acquired production disorder. A therapeutic transfusion policy may be considered for otherwise healthy patients experiencing a short period of pancytopaenia. The Platelet Transfusion Trigger for Prophylactic Platelet Transfusions for the Prevention of Spontaneous Haemorrhage 1. Inthecaseofastandardriskofbleeding,atransfusiontriggerof10x10 9/L is recommended for prophylactic platelet transfusions. 2.Ifthereareadditionalclinicalcomplicationsthatpromotebleeding,itisrecommendedthattheplatelet transfusion trigger be increased to 20 x 10 9/L for prophylactic platelet transfusions. 3.Forpatientswithanindicationforanti-coagulant treatment, it is recommended to increase the platelet transfusion trigger to 50 x 10 9/L in order to prevent spontaneous bleeding; this is not evidence based. 4.Forpatientswhohaverecently(past5days)experiencedaWorldHealthOrganization(WHO)grade>2bleed,itis recommended to increase the threshold for a platelet transfusion to 20 x 10 9/L and to analyse or remove other risk factors. Platelet Transfusion Dose in Platelet Transfusions for the Prevention of Spontaneous Bleeding A dose of approximately 3.5 x 10 11 (this is the dose of a standard preparation and contains 5 x 10 9 platelets/kg for a patient of 70 kg) is recommended for prophylactic platelet transfusions in adults. Platelet Transfusion Policy for the Prevention of Bleeding in (Elective) Procedures The following table can be used as a rule of thumb for platelet target values to prevent bleeding during common, elective procedures. Table: Target Values for Platelets During Procedures
Procedure Platelets x 10 /L
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Arthrocentesis Ascites/pleural puncture (thin needle) Ascites drain, pleural drain and pericardial drain Bone marrow aspiration Bone marrow biopsy (Jamshidi needle) Blind organ biopsy or puncture Bronchoscopy with biopsy or brush Insertion of central venous catheter Removal of central venous catheter Small intestine biopsy Electromyogram (EMG) Endoscopy + deep loop biopsy or polypectomy large polyp Endoscopy without biopsy Endoscopy with 'ordinary biopsy' Endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy Eye surgery (except cataract) Laparoscopy without biopsy Laparoscopy with biopsy or procedure Laser coagulation (not retina) Liver biopsy (percutaneous) Lumbar puncture Myelography, radiculo-saccography Neurosurgery Pacemaker implantation Percutaneous transhepatic cholangiography Plexus anaesthesia, epidural Seldinger arterial Muscle biopsy Sclerosing oesophageal varices Tooth/molar extractions Thoracoscopy/arthroscopy *In the case of leukaemic blasts in the peripheral blood: >50 x 10 9 /L

>50 N/A >50 N/A N/A >50 >50 >50 N/A >50 >20 >50 >20 >50 >50 >100 >50 >50 N/A >50 >20* >50 >100 >50 >50 >50 >50 >50 >50 >50 >50

Platelet Transfusions for the Treatment of Bleeding 1.Inthecaseofaseverebleed(WHOgrade3),plateletsshouldbetransfuseduntilthebleedingstopsand/orthe platelet count is >50 x 10 9/L. 2.Withrespecttobleedinginenclosedspacesofvitalorgans such as the brain, the nervous system and the eye the advice is to transfuse platelets to a platelet count of >100 x 10 9/L. Peripheral Thrombocytopenia Due to Antibodies Auto-immune Thrombocytopaenic Purpura (ITP) 1.ProphylacticplatelettransfusionsforthepreventionofspontaneousbleedingarenotindicatedinITP. 2.ForelectiveproceduresinITPpatients,therecommendedtreatmentisprednisoloneorIVIG,aloneorin combination with platelet transfusions if necessary. 3.WithITP,plateletsshouldpreferablybeadministeredafterIVIG. 4.InpatientswithITPandsevereWHOgrade>2bleeding,(highdose)platelettransfusionsarerecommendedand this is also the case if it is not possible to wait for the effect of a therapeutic dose of IVIG. 5.Seethetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. Post-transfusion Purpura (PTP) 1.Randomplatelettransfusionsarecontra-indicated for PTP.

2.ForelectiveproceduresinITPpatients,therecommendedtreatmentisprednisoloneorIVIG,aloneorin combination with platelet transfusions if necessary. 3.WithITP,plateletsshouldpreferablybeadministeredafterIVIG. 4.InpatientswithITPandsevereWHOgrade>2bleeding,(highdose)platelettransfusionsarerecommendedand this is also the case if it is not possible to wait for the effect of a therapeutic dose of IVIG. 5.Seethetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. Post-transfusion Purpura (PTP) 1.Randomplatelettransfusionsarecontra-indicated for PTP. 2.HighdoseIVIGisrecommendedastreatmentforPTP. 3.InthecaseofseverebleedingwithPTP,HPA-compatible transfusions are recommended in addition to IVIG. 4.Seealsothetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. Peripheral Thrombocytopenia Due to Consumption in Thrombotic Thrombocytopaenic Purpura (TTP), Haemolytic Uraemic Syndrome (HUS), Haemolysis Elevated Liver enzymes and Low Platelets (HELLP), Disseminated Intravascular Coagulopathy (DIC) and Heparin-Induced Thrombocytopenia (and Thrombosis) (HIT[T]) Prophylactic Platelet Transfusions in the Prevention of Spontaneous Bleeding in Thrombotic Micro-Angiopathy (TMA) 1.ProphylacticplatelettransfusionsarenotindicatedforTMAs. 2.InthecaseofTTP,prophylacticplatelettransfusionstopreventspontaneousbleedingareevendiscourageddue to a possible risk of occurrence or exacerbation of thrombo-emboli. 3.Seealsothetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. Prevention of Bleeding During Procedures in Patients with TMA 1.Forrelativelysimpleproceduressuchastheinsertionofacentralvenouscatheter(CVC)inthecaseofTTP, platelet transfusions are not recommended unless there is a strongly increased risk of bleeding, as is the case in severe obesity and severe thrombocytopenia <5 x 10 9/L. If it is decided to give platelet transfusions, the recommendation is to start preferably with the administration of plasma. 2.Inuseand/orbreakdowndisordersotherthanTTP,platelettransfusionsarerecommendedforthepreventionof bleeding during emergency procedures or vaginal delivery and Caesarian section in order to achieve a platelet count of >20 x 10 9/L or >50 x 10 9/L respectively. 3.Seealsothetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. HIT(T) 1.Thereisnoabsolutecontra-indication against a platelet transfusion in the case of WHO grade >2 bleeding in a patient with HIT(T) and adequate therapeutic treatment with alternative anti-coagulants. 2.Seealsothetable'IndicationsandContra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])' below. Table: Indications and Contra-indications for Platelet Transfusions in Thrombocytopenia Caused by Consumption and/or Breakdown Disorders (TTP, HUS, HELLP, DIC, ITP, PTP and HIT[T])
Prophylaxis Procedures Grade >2 Bleeding

TTP HUS DIC ITP PTP

Contra-indication If there is an increased risk, preferably after starting plasma therapy Consider No indication No indication No indication Consider Childbirth >2050 x 10 9 /L Consider Consider (+ IVIG or prednisolone) Consider provided (alternative) anti-coagulants Indication Indication Indication Indication (+ IVIG) HPA matched Provided (alternative) anti-coagulants

HELLP No indication

Contra-indication Contra-indication

HIT(T) No indication

Platelet Loss Due to Pooling in Splenomegaly For patients with thrombocytopenia due to splenomegaly, higher dosages of platelet transfusions are essential for the prevention and treatment of bleeding. Depending on the size of the spleen, 24 times the standard dose should be administered for a therapeutic transfusion. Acquired Thrombocytopathy 1.Inthecaseofacquiredthrombocytopathy,thepatientmaybetreateddependingonthecauseandtheseverityof the bleeding or the nature of the scheduled procedure. 2. Forthrombocytopenia<50x10 9/L and thrombocytopathy, platelet transfusions are advised for procedures and bleeding and before administration of desmopressin. 3.Plasmapheresisisrecommendedforthrombocytopathicbleedingwithhyperviscositysyndromecausedbyaparaprotein. 4.Oneshouldtakeintoconsiderationthattheeffectofdesmopressinbecomesexhaustedafteraprocedureandthat a second dose should therefore be administered after 24 hours. Thrombocytopathy Due to Use of Medication 1.Ifthereareindicationsnottostoptheuseofacetylsalicylicacid(aspirin)andclopidogrelbeforeacardiovascular procedure, one should take into account that increased blood loss can occur. 2.Inthecaseofproceduresinnon-critical locations, the use of aspirin does not need to be halted before the procedure. 3.Forelectivesurgeryincritical(enclosedspace:brain,eye,innerear,etc.)locations,theuseofaspirinshouldbe halted at least 5 days before the procedure. 4.Foremergencyproceduresorbleedingunderaspirintherapy,astandarddoseplatelettransfusionshouldbe sufficient; at least 2 doses are necessary in the case of combined use with clopidogrel. 5.Researchisnecessarytodeterminethebenefitofplatelettransfusionsin(cerebral)haemorrhageduringtheuseof platelet inhibitors.

procedure, one should take into account that increased blood loss can occur. 2.Inthecaseofproceduresinnon-critical locations, the use of aspirin does not need to be halted before the procedure. 3.Forelectivesurgeryincritical(enclosedspace:brain,eye,innerear,etc.)locations,theuseofaspirinshouldbe halted at least 5 days before the procedure. 4.Foremergencyproceduresorbleedingunderaspirintherapy,astandarddoseplatelettransfusionshouldbe sufficient; at least 2 doses are necessary in the case of combined use with clopidogrel. 5.Researchisnecessarytodeterminethebenefitofplatelettransfusionsin(cerebral)haemorrhageduringtheuseof platelet inhibitors. 6.Platelettransfusions alone or in combination with desmopressin are necessary in the case of an acute intervention with the use of anti-IIb/IIIa inhibitors in order to absorb the antibodies. Platelet Transfusions in Practice Selection of Human Leukocyte Antigen (HLA) (HPA) Compatible Donors 1.ScreeningforHLAantibodiesisrecommendedifthe1-hour corrected count increment (CCI) of a fresh ABO compatible platelet transfusion is <7.5 twice in a row in a patient without clinical factors that could explain this (this is then a case of platelet refractoriness). 2.IfABOandHLAcompatibletransfusionsresultinaCCI<7.5 in the absence of clinical factors that could explain this serological analysis for platelet specific antigens (HPA) is recommended. 3.Theworkinggroupisoftheopinionthatcommunicationbetweentreatingdoctor,hospitaltransfusionserviceand the Clinical Consultative Service of the Blood Supplier is essential for effective implementation and support with HLA matched platelet transfusions. ABO/Rh-D Selection See ' Platelet characteristics' in the NGC summary of the DIHG guideline Blood components: characteristics, indications, logistics and administration and 'ABO Compatibility of Platelets' in the NGC summary of the DIHG guideline Laboratory aspects. Supporting Treatments for Therapy-Resistant Bleeding Erythrocyte Transfusion, Inhibition of Fibrinolysis and Recombinant Factor VIIa (rFVIIa) Erythrocyte Transfusions 1.Forpatientswiththrombocytopeniaandbleeding who cannot be, or are poorly, corrected with platelet transfusions, it is recommended to consider increasing the haematocrit to >0.30 L/L in order to reduce the tendency to bleed. 2.Inpatientswiththrombocytopeniaandmucousmembranebleeding(bleedingfromnoseandgums,menorrhagia), anti-fibrinolytic medication can be considered to reduce the tendency to bleed. Fibrinolysis inhibition is contraindicated in haematuria because of the risk of thrombus formation in the urinary tract. 3.Itisrecommendedthata(preferablynational)registrationtakesplaceoftheuseofrFVIIaforbleedinginpatients with thrombocytopenia and that protocols be developed for evaluation and reporting of the effect of the use of rFVIIa for this indication. IVIG Administration of IVIG before a platelet transfusion is not recommended in the case of refractoriness due to HLA antibodies. Plasma Transfusions for Non-surgical Patients See 'Plasma' in the NGC summary of the DIHG guideline Blood components: characteristics, indications, logistics and administration for the indications for plasma. Plasma Transfusions in Children 1.Treatmentwithplasmaorplasmapheresisisgenerallynotindicatedinchildrenwithd+HUS. 2. Treatmentwithplasmaorplasmapheresisisrecommendedforchildrenwithatypical(d neg ) HUS or recurrent HUS in a transplanted kidney. 3.Aftertherapeuticplasmaadministration,prophylacticplasmatransfusionsareindicatedinchildrenwithTTPcaused by a congenital ADAMTS-13 deficiency. Plasma Transfusions in Adults Plasmapheresis for Primary TMAs 1.TreatmentofHELLPsyndromewithplasma(pheresis)isnotrecommended,unlesstherehasbeeneitherno improvement or deterioration has occurred >72 hours post-partum. 2. PlasmaadministrationisrecommendedastherapyofchoiceforTTPandforatypical(d neg ) HUS. 3.Plasmaadministration/plasmapheresisisindicatedforTTPandHUSbeforeorshortlyafterchildbirth. 4.Plasmapheresisispreferredtoplasmatransfusionforthetreatmentofthromboticthrombocytopaenicpurpura (TTP) or atypical (d neg ) HUS. 5.Forthetimebeing,methylenebluetreatedplasmaisnotrecommendedforthetreatmentofthromboticmicroangiopathies (TMA)/thrombotic thrombocytopaenic purpura (TTP). Secondary TMAs 1.Plasma(pheresis)isnotrecommendedforTMAassociatedwithextensivelymetastasisedcarcinoma. 2.Plasma(pheresis)isnotrecommendedforpoststemcelltransplant(SCT)andpostbonemarrowtransplant(BMT) induced TMA. 3.Plasma(pheresis)isnotrecommendedforTMAcausedbycytostatics. 4.Plasma(pheresis)isnotrecommendedforcyclosporinAortacrolimus(FK506)inducedTMA. 5.PlasmapheresisisrecommendedforTMAinducedbyticlopidine,clopidogrelandanumberofothermedications. 6.PlasmapheresisisrecommendedforHIVinducedTMA. 7.PlasmapheresiscanbeconsideredintherarecombinationofTMAandcatastrophicanti-phospholipid syndrome if standard treatment provides insufficient effect. Supplementation of Clotting Factors for Deficiencies 1.Inthecaseofprocedures,itisrecommendedtotakeintoconsiderationthedilutioncoagulopathydueto

3.Plasma(pheresis)isnotrecommendedforTMAcausedbycytostatics. 4.Plasma(pheresis)isnotrecommendedforcyclosporinAortacrolimus(FK506)inducedTMA. 5.PlasmapheresisisrecommendedforTMAinducedbyticlopidine,clopidogrelandanumberofothermedications. 6.PlasmapheresisisrecommendedforHIVinducedTMA. 7.PlasmapheresiscanbeconsideredintherarecombinationofTMAandcatastrophicanti-phospholipid syndrome if standard treatment provides insufficient effect. Supplementation of Clotting Factors for Deficiencies 1.Inthecaseofprocedures,itisrecommendedtotakeintoconsiderationthedilutioncoagulopathydueto plasmapheresis treatment with a daily frequency (or every other day) without plasma as substitution liquid. 2.TreatmentwithplasmadoesnothavearoleinvitaminKdeficiencyand/orthetaperingoforalanti-coagulants (vitamin K antagonists). 3.Forthetaperingofanti-fibrinolytics in the case of bleeding, it is recommended to administer plasma or a fibrinogen preparation based on aPTT and fibrinogen level in addition to tranexamic acid in the case of an prolonged activated partial thromboplastin time (aPTT) and a low fibrinogen level. Plasma Transfusion Policy for Severe DIC with Bleeding In patients with DIC who are bleeding, need to undergo an invasive procedure or have some other severe risk of bleeding, treatment with plasma, supplemented by a fibrinogen concentrate if necessary, should be considered. Plasma Component Choice and Blood Group Incompatibility 1.Furtherresearchisessentialtobeabletorecommendtheoptimalplasmacomponentinrelationtoindicationand patient. 2.FurtherresearchontheeffectsofABOcompatiblebutnotABOidenticalplasmaisrecommendedanditis preferable to transfuse in an ABO identical manner. Clinical Algorithm(s) None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits Appropriate and safe management of patients who might require platelet or plasma transfusions Potential Harms Systematicreviewsconcludedthatmoreresearchisnecessarybeforeconclusionscanbedrawnontheefficacyand adverse effects of the various plasma components.
l

Dilutioncoagulopathycanoccurinthecaseofdailyplasmapheresis(oreveryotherday)withanon-plasma substitution agent. Thrombosis has been described incidentally with the use of albumin as a substitution liquid; the estimated incidence is 0.060% to 0.14%. Bleeding has very rarely been described.
l

Theeffectofdesmopressinhasnotbeenexaminedinthrombocytopenia<50x109/Landisnotauthorisedforusein pregnancy or with suspected cerebral haemorrhage. Cerebral and cardiac infarction have been described as complications in renal patients. It is useful to determine the bleeding time to monitor the effect of desmopressin.
l

Inthecaseofthromboticthrombocytopaenicpurpura(TTP),prophylacticplatelettransfusionstoprevent spontaneous bleeding are discouraged due to a possible risk of occurrence or exacerbation of thrombo-emboli.
l

See also the National Guideline Clearinghouse (NGC) summary of the Dutch Institute for Healthcare Improvement Centraal BegeleidingsOrgaan (CBO) (DIHG) guideline Transfusion reactions and related conditions.

Contraindications
Contraindications Therearemanysub-types of type 2 von Willebrand Disease (vWD) and desmopressin is contra-indicated for type 2B because it can cause platelet aggregation and thrombocytopenia. Type 2A is treatable with desmopressin. Desmopressin is not effective for the very rare type 3.
l l l l

Desmopressinisalsocontra-indicated in cardiac decompensation. Prophylacticandprocedure-related platelet transfusions are contra-indicated for post-transfusion purpura (PTP).

Platelettransfusioniscontra-indicated for thrombotic thrombocytopaenic purpura (TTP), because the occurrence of cerebral infarction has been described following platelet transfusions. A review of the literature shows that there is no convincing evidence of damage due to platelet transfusions in TTP patients. The efficacy of prophylactic platelet transfusions for TTP has also not been demonstrated. Theguidelineonneuraxisblockadeandanti-coagulants states that every form of neuraxis blockade is contraindicated with IIb/IIIa inhibitors.
l l l

Fibrinolysisinhibitioniscontra-indicated in haematuria due to the risk of thrombus formation in the urinary tract. Randomplatelettransfusionsarecontra-indicated for post-transfusion purpura (PTP).

Qualifying Statements

convincing evidence of damage due to platelet transfusions in TTP patients. The efficacy of prophylactic platelet transfusions for TTP has also not been demonstrated. Theguidelineonneuraxisblockadeandanti-coagulants states that every form of neuraxis blockade is contraindicated with IIb/IIIa inhibitors.
l l l

Fibrinolysisinhibitioniscontra-indicated in haematuria due to the risk of thrombus formation in the urinary tract. Randomplatelettransfusionsarecontra-indicated for post-transfusion purpura (PTP).

Qualifying Statements
Qualifying Statements Guidelines are not legal instructions, but rather scientifically substantiated and/or broadly accepted insights and recommendations that care providers should follow in order to offer good quality care. As guidelines are based on 'the average patient', care providers can, if necessary, deviate from the recommendations in the guideline in individual cases. Sometimes it may even be essential to deviate from guidelines if the patient's situation demands this. However, if a conscious decision is made to deviate from the guideline, a case must be made for this and it must be documented. One should also consider whether this should be discussed with the patient, or whether the patient should be informed.

Implementation of the Guideline

Description of Implementation Strategy The guideline was initially disseminated through the websites of scientific and professional associations that were involved and made available through the website of the Centraal BegeleidingsOrgaan (CBO; www.cbo.nl ). The definitive guideline will be disseminated amongst the associations and will be available in digital format. The recommendations of the guideline will be presented at scientific meetings of the relevant scientific associations. An announcement of this guideline will be submitted for publication to the Netherlands Journal of Medicine, the Journal for Blood Transfusion and the Netherlands Journal of Clinical Chemistry and Laboratory Medicine. In order to stimulate the implementation and evaluation of this guideline, internal indicators have been developed, which allow for the implementation to be measured by random sampling. In general, indicators give the care providers the opportunity to evaluate whether they are providing the desired care. This enables them also to identify subjects for improvement of the care provision. The internal indicators that were developed for this guideline are discussed in Chapter 9 of the original guideline document. Implementation Tools Audit Criteria/Indicators Foreign Language Translations Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need Getting Better Living with Illness Staying Healthy IOM Domain Effectiveness Safety

Identifying Information and Availability

Bibliographic Source(s) Platelet and plasma transfusion policy. In: Blood transfusion guideline. Utrecht (The Netherlands): Dutch Institute for Healthcare Improvement CBO; 2011. p. 209-77. [291 references] Adaptation Not applicable: The guideline was not adapted from another source. Date Released 2011 Guideline Developer(s) Dutch Institute for Healthcare Improvement CBO - Professional Association Source(s) of Funding The Blood Transfusion Policy guideline project was financed by The Netherlands Organisation for Health Research and Development (ZonMw) within the programme Knowledge Policy Quality of Curative Care. The Dutch Institute for Healthcare Improvement Centraal BegeleidingsOrgaan (CBO) (DIHG) is extremely grateful to the Sanquin Blood Supply Foundation for financing this translation. Guideline Committee

Dutch Institute for Healthcare Improvement CBO - Professional Association Source(s) of Funding The Blood Transfusion Policy guideline project was financed by The Netherlands Organisation for Health Research and Development (ZonMw) within the programme Knowledge Policy Quality of Curative Care. The Dutch Institute for Healthcare Improvement Centraal BegeleidingsOrgaan (CBO) (DIHG) is extremely grateful to the Sanquin Blood Supply Foundation for financing this translation. Guideline Committee Dutch Institute for Healthcare Improvement Centraal BegeleidingsOrgaan (CBO) (DIHG) Working Group Composition of Group That Authored the Guideline Core Group Members: F.J.L.M. Haas (Chairman), Prof. D.J. van Rhenen, Prof. R.R.P. de Vries (Chairman), Mrs M.A.M. Overbeeke, Dr V.M.J. Novotny, Dr Ch.P. Henny Working Group Members: Prof. A. Brand, internist-haematologist, manager of research & education, Sanquin Blood Supply Region SW, Department of Research & Education, Leiden; Ms H. de Bruijn-van Beek, general secretary board, Sanquin Blood Supply, Amsterdam; Dr C.L. van der Poel, transfusion doctor-epidemiologist, Secretary for medical affairs, Sanquin Blood Supply, Group personnel, Amsterdam; Dr E.A.M. Beckers, transfusion specialist, University Medical Centre, Haematology Department, Maastricht; T. Reker, transplant coordinator, University Medical Centre, Groningen [until 01-052009]; Ms N.W.M. Gerrits, senior nurse haematology/oncology, Onze Lieve Vrouwe Gasthuis, ward C6, Amsterdam; Dr Ch.P. Henny, anaesthesiologist, Academic Medical Centre, Anaesthesiology department, Amsterdam; Dr A.W.M.M. Koopman-van Gemert, anaesthesiologist-intensivist, Albert Schweitzer Hospital, location Dordtwijk, Anaesthesiology department, Dordrecht; Dr A.W.M.M. Koopman-van Gemert, anaesthesiologist-intensivist, Albert Schweitzer Hospital, location Dordtwijk, Anaesthesiology department, Dordrecht; Dr V.M.J. Novotny, internist-haematologist/blood transfusion specialist, St. Radboud University Medical Centre, Haematology department, Nijmegen; Mrs M.A.M. Overbeeke, biologist, head of Immunohaematology department, Sanquin Blood Supply, Diagnostics Division, Amsterdam; Mrs M. Smelt, haemovigilance employee, St. Antonius Hospital, Clinical Chemistry Laboratory, Nieuwegein; Dr M.R. Schipperus, internisthaematologist,HagaHospital,Haematologydepartment,TheHagueDrJ.Schnberger,cardiothoracicsurgeon,Catharina Hospital, Department of Cardiothoracic Surgery, Eindhoven; Dr R.Y.J. Tamminga, paediatrician, oncologist-haematologist, University Medical Centre, Beatrix Children's Clinic, Groningen; Dr C.H. van Ommen, paediatrician-haematologist, Academic Medical Centre, department of Paediatric Haematology, Amsterdam; Dr. E. Lopriore, paediatricianneonatologist, Leiden University Medical Centre, department of neonatology, Leiden; Dr R.C.R.M. Vossen, clinical chemist, Orbis Medical Centre, clinical chemistry & haematology laboratory, Sittard; Dr J. Slomp, clinical chemist, Medical Spectrum Twente, Laboratory, Enschede; Prof. D.J. van Rhenen, internist-haematologist, division director Sanquin Blood Supply, SW Region, Rotterdam; Dr J.J. Zwaginga, staff member blood transfusion service, head of stem cell therapy centre, Leiden University Medical Centre, department of Immunohaematology, Leiden; Dr B.J. Biemond, internist-haematologist, Academic Medical Centre/University of Amsterdam, department of Internal Medicine, Amsterdam; Dr J.Th.M. de Wolf, internist-haematologist, University Medical Centre, Groningen (until 01-04-2009); Dr R.E.G. Schutgens, internisthaematologist, University Medical Centre, Utrecht (as of 15-04-2009); Dr P.J. Kabel, physician-microbiologist, Regional Laboratory for Public Health, LMMI department, Tilburg; Dr G.C.M.L. Page-Christiaens, perinatologist, University Medical Centre, Obstetric department, Utrecht; Dr J.G. Loeber, clinical chemist, head of laboratory, RIVM, LIS department, Bilthoven (Chapter 9: Indicators); Dr A. Castel (up to and including February 2009); Dr Y.B. de Rijke, (as of March 2009), clinical chemist, Erasmus Medical Centre, department of Clinical Chemistry, Rotterdam; H.E. Polak, anaesthesiology nurse, Via Sana Clinic, Mill; Prof. R.J. Porte, University Medical Centre, department of Surgery, Groningen; W.G. Horstmann (up to and including March 2009)]; D.B. van der Schaaf, orthopaedic surgeon, Sint Maartens Clinic, Orthopaedics department, Nijmegen (as of April 2009) Financial Disclosures/Conflicts of Interest No relationships relevant to this guideline of working group members with the pharmaceutical industry were reported. Guideline Status This is the current release of the guideline. Guideline Availability Electronic copies: Available in English and Dutch from http://www.diliguide.nl/document/2903 . Availability of Companion Documents Quality indicators are available in Chapter 9 of the original guideline document . In addition, a pocket guide is available in Dutch from http://www.diliguide.nl/document/2903 . Patient Resources None available NGC Status This NGC summary was completed by ECRI Institute on October 9, 2012. The information was verified by the guideline developer on November 14, 2012. Copyright Statement This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer
NGC Disclaimer TheNationalGuidelineClearinghouse(NGC)doesnotdevelop,produce,approve,orendorsetheguidelinesrepresented on this site.

Copyright Statement This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer
NGC Disclaimer TheNationalGuidelineClearinghouse(NGC)doesnotdevelop,produce,approve,orendorsetheguidelinesrepresented on this site. All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities. Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx. NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes. Readers with questions regarding guideline content are directed to contact the guideline developer.