Almost all sports medicine doctors agree that there’s no harm in trying Platelet Rich Plasma Injections (PRP Injections) for their patients. After all, there are hundreds of thousands of cases with positive results. All it needs is research to prove its worth. Currently, many independent researches are ongoing, funded privately, like the one conducted by Dr. Kimberly G. Harmon M.D., director of the Primary Care Sports Medicine fellowship at the University of Washington. She recently received a gift to support her research from UW alumni who firmly believe in Platelet-Rich Plasma (PRP).

While the process of extracting PRP is fairly simple—there are many variants as long as platelets are above baseline levels with at least seven growth factors—many physicians are still unsure about what they can and can’t do when it comes to this marvelous procedure. Today, let’s shed light on the fine print.

Platelet-Rich Plasma Injections Protocol

Protocol/Technique

Usually, the procedure requires the physician/surgeon and an assistant or two to help with the preparation of the graft, maintenance of sterile technique, and saving the ultrasound images (if relevant).

Pre-Procedure Considerations

• There should always be a specific indication associated with a physical exam with confirmed imaging studies such as an ultrasound, CT scan, or MRI before treatment.
• Proper patient education and a discussion must be had with the patient, as well as a signed informed consent prior to the procedure.
• Contraindications must be reviewed prior to the procedure.

Graft Preparation

• The patient should be positioned in a comfortable seated or reclining position.
• Sterile single needles and syringes must be used with proper handling and disposal.
• Using an aseptic procedure, the proper amount of blood is then drawn from the vein for the PRP procedure.
• If the blood cannot be obtained from the site the first time, a new site must be used to prevent early activation.
• Using a sterile technique, transfer the tube of venous blood to the centrifuge. Platelet-Rich Plasma should be acquired using a separating device created for autologous blood. Preference is always given to a closed system that will prevent exposure of the blood and its cellular components to the open air, and permits minimal use of the tissue.

Image Guidance PRP Therapy

• Real-time imaging guidance using ultrasound, CT, or fluoroscopy should always be used when performing a PRP injection.
• If ultrasound is going to be used, the following considerations need to be decided in advance: For lengthy procedures, PRP injections near the spine, and intra-articular injections, sterile gel is recommended.
• Always use sterile probe covers. Cleansing the probe before and after the PRP procedures and observing sterile technique is sufficient.
• Guided images and indelible markings of the site of the probe position and the needle entry always need to be made before cleaning the skin where the probe and needle will be inserted.
• Always apply a bandage or a dressing after the procedure to protect the entry site from germs.

Post-Injection Care

• The patient should be monitored for any post-PRP procedure complications such as vaso-vagal reactions.
• Patients should be given post-procedure directions and precautions, and any questions should be answered before they leave. They should also have emergency contact information.
• Patients should be instructed about immobilization and any post-procedure activities that are allowed and/or not allowed.
• Post-PRP procedure pain prescriptions need to be given to the patient before discharge, and any questions about the medication(s) should be answered at this time. Patients also need to be instructed to avoid NSAIDs until they have healed, are pain-free, and have full function returned to the treated area.
• Per OSHA guidelines, contaminated areas must be disinfected before the next patient uses the room.
• The PRP procedure must be documented in detail, including a procedure note with the following information: date, pre- and post-procedure diagnosis, name of the procedure, physician/surgeon(s), any assistants, whether or not anesthesia was used and what type, short-term indication of the procedure, a description of the graft preparation, and a description of the procedure, including any/all guidance and instruments used.

Follow-up Care

• Patients are normally re-examined 2-6 weeks after the PRP procedure to follow up on pain, use, the injection site, and to discuss any concerns and future course of action.
• The patient response to the treatment should be recorded using authenticated outcome measures.
• Any complications, responses, and all other relevant information should be logged into the ICMS tracking system.
• Consideration for another PRP injection should be the center of the discussion, and the patient will be able to make a decision based on the outcome.

Safety Considerations

• Universal precautions must be used before, during, and after the procedure.
• Risk of infection: PRP is antimicrobial and provides effective protection against most bacterial infections except for Klebsiella, Pseudomonas, and Enterococcus.
• With the graft being made entirely out of autologous blood, it virtually eliminates the risk of disease transmission unless the graft becomes contaminated.

Risks to Patients from the Procedure

• Infection
• Bleeding
• Nerve damage
• Pain
• Lack of result
• Loss of limb and death (very rare)

Platelet-Rich Plasma: Indications

Musculoskeletal complaints require a complete history and exam to find a diagnosis. Often, diagnostic studies may be needed and reviewed to understand why prior treatments failed. PRP is usually considered an optional treatment for chronic and subacute conditions. Commonly, healing slows down or stops altogether at the 6-12 week period following an acute or traumatic injury. If the patient has not had any improvement for over the first six weeks, it’s probable the healing period has stopped.

Platelet-Rich Plasma: Contraindications

• Septicemia
• Platelet dysfunction syndrome
• Localized infection at the procedure site
• Hemodynamic instability
• Critical thrombocytopenia
• Patient not willing to take the risks involved with the procedure

Relative Contraindications:

• Regular use of NSAIDs within 48 hours of the PRP procedure
• HGB of < 10 g/dl
• Platelet count of < 105/ul
• Systemic use of corticosteroids within 2 weeks
• Recent illness or fever
• Cancer, particularly hematopoietic or bone
• HGB < 10 g/dl
• Platelet count < 105/ul
• Corticosteroid injection at the treatment site within 1 month
• Tobacco use