Critical Bleeding in Adults and Children with Immune Thrombocytopenia: A Multicenter Cohort Study

Critical bleeding in patients with immune thrombocytopenia (ITP) is a life-threatening hematological emergency. The objective of this study was to describe the frequency, management, and outcomes of critical bleeds among adults and children with ITP. We conducted a retrospective cohort study of patients with ITP who presented to the emergency room (ER) with a platelet count <20 x109/L across 7 centers in the United States and Canada between 2010 and 2019. Of 1226 patients (n=296 adults; n=930 children), 28 (2.3%) had a critical bleed (n=15 adults, median age 68 years; n=13 children, median age 11 years). Of patients with a critical bleed, 12 adults (80.0%) and 6 children (46.2%) had intracranial hemorrhage (ICH). For adults, the common interventions used to treat critical bleeds were platelet transfusions (n=11; 73.3%), corticosteroids (n=10; 66.7%), and intravenous immune globulin (IVIG) (n=8; 53.3%); and for children, common interventions were IVIG (n=10; 76.9%), corticosteroids (n=8; 61.5%), platelet transfusions (n=8; 61.5%), thrombopoietin receptor agonists (n=4; 30.8%), and antifibrinolytic agents (tranexamic acid or aminocaproic acid, n=4; 30.8%). For both adults and children, the most common treatment combination was corticosteroids, IVIG, and platelet transfusion (n=6; 40.0% vs. n=6; 46.2%). The median time from presentation to first treatment was 6.9 hours for adults and 3.5 hours for children. Overall, 9 (32.1%) patients with critical ITP bleeds died, including 7 adults (46.7%) and 2 children (15.4%). Critical bleeding in patients with ITP was rare but frequently fatal, especially among older adults with ICH and when treatments were delayed.