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Gawd, this annoys me. There is no evidence out there to support the fact that minimally invasive procedures (like thoracentesis, LP, central line insertion) require a platelet count of 50,000 or higher in order to be done safely, yet here at this hospital the surgeons or radiologist frequently insist on having a platelet count of 50,000 before they will do the procedure. Today, this meant that they were requesting platelets for a woman with a count of 45,000 so that she could "safely" get her thoracentesis. This is such BS. Studies from years ago showed that a count of 20,000 is basically safe for procedures like this, and 50,000 is probably required for certain procedures like CABG or liver transplant.
So a frequent patient is the bone marrow transplant patient who hangs out at a platelet count of 20,000. Interventional radiology insists on a platelet count of 50,000 to do the procedure. We tell them the most effective way to do the procedure is to run in one 5 pack of platelets immediately before the procedure, if not concurrently with the procedure, as this provides the best results in someone who is going to consume any transfused platelets almost immediately. If the 5 pack bumps up their platelets to 50,000, if you were to check 2 hours later it would probably be back to 20,000 or whatever this person's steady state is. But they don't want the most effective results. They want a count of 50,000, even if that count was 3 hours prior to the procedure.
Case of the day: 17 year old boy with hemophagocytic syndrome. Platelet count averages 10-15 daily. Gets transfusions once a day or every other day, but the bump he gets is wiped out in 2 hours. Sample:
6am cbc: Platelets 15
11am transfusion of platelets (after rounds)
12:30 pm CBC after transfusion: platelets 40
1:30 pm CBC: Platelets 16.
Today, patient is getting a tracheostomy and LP in the OR. Surgeon demands "two five packs of platelets no later than 1pm" (surgery is at 3pm at the earliest) "as well as two five packs when patient gets to the OR to attain platelet count of at least 100,000." Both I and my attending talked to the staff yesterday about this patient, and how any operation will have to be done with platelet transfusion during the procedure, but not earlier in the day, because they will have no effect unless proximate to the surgery. We got FIVE calls today from residents and attendings, all asking for more platelets to "increase his counts prior to surgery." Every time we explained it to them, and every time they seemingly agreed. The deal: You will get 2 five packs of platelets when you get to the OR. Give him the first one while inducing anesthesia, run in the second one slowly during the procedure. If he bleeds following surgery, we will give more.
What do they do? Patient gets to OR at 3:30 pm, gets both 5 packs of platelets before 4pm. Incision is at 4:45. Nobody understands!
I blame the damn lawyers. Because the IR folks (and surgeons) have their hands tied. If there is a complication. They will ask "What was the preop platelet count?" Well, if the procedure was at noon and the last platelet count was at 6am and was 55,000 immediately after a transfusion, they can say, "55,000!" If the 6am count was 19,000 and the patient didn't get platelets until the OR, and no second count was drawn, they may very well get skewered for this. Damn lawyers. Show me the evidence you bloodsuckers!
So a frequent patient is the bone marrow transplant patient who hangs out at a platelet count of 20,000. Interventional radiology insists on a platelet count of 50,000 to do the procedure. We tell them the most effective way to do the procedure is to run in one 5 pack of platelets immediately before the procedure, if not concurrently with the procedure, as this provides the best results in someone who is going to consume any transfused platelets almost immediately. If the 5 pack bumps up their platelets to 50,000, if you were to check 2 hours later it would probably be back to 20,000 or whatever this person's steady state is. But they don't want the most effective results. They want a count of 50,000, even if that count was 3 hours prior to the procedure.
Case of the day: 17 year old boy with hemophagocytic syndrome. Platelet count averages 10-15 daily. Gets transfusions once a day or every other day, but the bump he gets is wiped out in 2 hours. Sample:
6am cbc: Platelets 15
11am transfusion of platelets (after rounds)
12:30 pm CBC after transfusion: platelets 40
1:30 pm CBC: Platelets 16.
Today, patient is getting a tracheostomy and LP in the OR. Surgeon demands "two five packs of platelets no later than 1pm" (surgery is at 3pm at the earliest) "as well as two five packs when patient gets to the OR to attain platelet count of at least 100,000." Both I and my attending talked to the staff yesterday about this patient, and how any operation will have to be done with platelet transfusion during the procedure, but not earlier in the day, because they will have no effect unless proximate to the surgery. We got FIVE calls today from residents and attendings, all asking for more platelets to "increase his counts prior to surgery." Every time we explained it to them, and every time they seemingly agreed. The deal: You will get 2 five packs of platelets when you get to the OR. Give him the first one while inducing anesthesia, run in the second one slowly during the procedure. If he bleeds following surgery, we will give more.
What do they do? Patient gets to OR at 3:30 pm, gets both 5 packs of platelets before 4pm. Incision is at 4:45. Nobody understands!
I blame the damn lawyers. Because the IR folks (and surgeons) have their hands tied. If there is a complication. They will ask "What was the preop platelet count?" Well, if the procedure was at noon and the last platelet count was at 6am and was 55,000 immediately after a transfusion, they can say, "55,000!" If the 6am count was 19,000 and the patient didn't get platelets until the OR, and no second count was drawn, they may very well get skewered for this. Damn lawyers. Show me the evidence you bloodsuckers!