Neuraxial anesthesia, the numbers.

[CodeBlu]

Had a discussion about spinal vs. epidural anesthesia today... I know the number that is often quoted is platelets of 100 or greater.


What's the lowest platelet count you would even consider for neuraxial anesthesia?

The lowest number I got was between 70-80. Apparently there is a case report of a patient developing an epidural hematoma with associated paralysis at a count of 71.

Thoughts?

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[chmd]

50 for spinal right? What about a spinal after 5 days of plavix, is that older teaching? Anyone think 5 days is enough?

I also know there are people who won't allow lovenox prophylaxis with indwelling epidural but I'm almost certain we allowed that in residency.

 

[Noyac]

Depends on the case and the situation. There is no set number you must go by.
1) labor epidural at 2am- >100
2) thoracic epidural for bowel resection on a healthy guy >100
3) thoracic epidural for bowel resection on a resp cripple>80
4)spinal for THA in healthy pt>80
5) spinal for THA in a resp cripple >50
6) spinal for THA in a cardiac cripple on plavix, off for 5 days->80

I could go on but these are all moving targets and subject to change at my discretion on a case by case basis.

 

[B-Bone]

It's always a risks vs benefits situation with platelets, and the trend is important as well. I'll usually do a labor epidural down to about 75,000 if it's stable, but not if it was 150,000 six hours ago. Epidurals are almost always elective procedures for pain control )at least when I do them), so I don't generally see a reason to get all cowboy wth them. Spinals I may go lower if there's a good reason and I feel that the risk of spinal hematoma is lower than the risk of some other bad outcome with GA. I always think about the peds oncology pts I saw in residency where hematologists and IR folks were placing intrathecal chemotherapy with plt levels of like 5,000. Risks vs benefits. I have some partners who won't do any neuraxial less than 100,000 and others who think 50,000 is fine no matter what.

With regards to plavix, lovenox, etc, I'm a bit more conservative, given that there are well-established, published guidelines for neuraxial (ASRA) with these things. With plavix you can always check a platelet function assay since there are so many non-responders, and I'm OK doing neuraxial at less than 7 days off plavix in that situation. In general, though, I abide the ASRA guidelines unless there is a really good reason not to. In that case I have a frank discussion with the patient about risks/benefits/etc and do what I need to do.

 

[B-Bone]

Depends on the case and the situation. There is no set number you must go by.
1) labor epidural at 2am- >100
2) thoracic epidural for bowel resection on a healthy guy >100
3) thoracic epidural for bowel resection on a resp cripple>80
4)spinal for THA in healthy pt>80
5) spinal for THA in a resp cripple >50
6) spinal for THA in a cardiac cripple on plavix, off for 5 days->80

I could go on but these are all moving targets and subject to change at my discretion on a case by case basis.

This does beg the question, what surgeon is cool doing a THA with platelets of 50,000 and why does a true respiratory cripple need a THA? Is he playing ultimate frisbee on the weekends?

 

[Noyac]

I forgot one
Labor epidural at a decent hour >75.

Lots of times labor pts are provider dependent and I may choose not to get involved depending on the provider.

But as I said, 2am and I'm not coming in to the hospital for anything <100.

 

[urge]

Why is it that pediatricians are so comfortable placing spinal chemo with plt count of 20k? They never seem to get into trouble.

 

[deleted126335]

not all thrombocytopenia is created equal. The peds on folks don't have too many alternatives to IT chemo. We almost always have an alternative-(GA).

 

[urge]

not all thrombocytopenia is created equal. The peds on folks don't have too many alternatives to IT chemo. We almost always have an alternative-(GA).

They could transfuse plts before.

 

[Mman]

Why is it that pediatricians are so comfortable placing spinal chemo with plt count of 20k? They never seem to get into trouble.

because their patients are going to die without the chemotherapy.

I've yet to have a patient that was going to die without an epidural or spinal.

 

[GatorBait1548]

Very interesting discussion, thank you to attendings for the input

 

[pgg]

It's all risk benefit. We went to medical school and did a residency for the broad and deep medical background, so we could one day make intelligent judgment calls.

Why is it that pediatricians are so comfortable placing spinal chemo with plt count of 20k? They never seem to get into trouble.

The risk of a catastrophic injury in a thrombocytopenia patient who gets a spinal is very very low, and the benefit of chemo is very very high.

For us, the risk of such an injury is still likely very very low, particularly with a single pass and a small needle ... but the benefit is less pronounced when pent-sux-tube is usually a viable alternative.

Also, the smartass in me can't help but think maybe part of it is the same reason a hospitalist called me last week asking for a blood patch for a postural headache in a septic patient with 50 platelets ... maybe they just don't understand the risk.

 

[Noyac]

because their patients are going to die without the chemotherapy.

I've yet to have a patient that was going to die without an epidural or spinal.

You obviously haven't met some of my OB pts.

 

[Noyac]

Our newer anticoagulants get my attention more than low plts do.

 

[fakin' the funk]

Our newer anticoagulants get my attention more than low plts do.

+1.

I postponed a THA on a 80ish year old semi demented lady who'd been on apixaban for Afib anticoagulation. Primary care doc wanted to get "just one more dose" in the pt prior to being off perioperatively. Pt presents for THA 30 hours after last apixaban dose. I know many would have done GA and been done with it, but surgeon and PCP felt this pt was demented enough she'd have a rough postop course (i.e. high risk of delirium) if getting GA. So we all mutually postponed until they could get the apixaban timing right (> 48 or > 72 h, depending on where you look). Incidentally, surgeon was OK with doing THA 30 hours post last dose...

 

[Mman]

You obviously haven't met some of my OB pts.

Oh, I've met them. And when their plt count is 59K I explain that an epidural hematoma and risk of paralysis for the sake of a labor epidural isn't worth it.

 

[Noyac]

+1.

I postponed a THA on a 80ish year old semi demented lady who'd been on apixaban for Afib anticoagulation. Primary care doc wanted to get "just one more dose" in the pt prior to being off perioperatively. Pt presents for THA 30 hours after last apixaban dose. I know many would have done GA and been done with it, but surgeon and PCP felt this pt was demented enough she'd have a rough postop course (i.e. high risk of delirium) if getting GA. So we all mutually postponed until they could get the apixaban timing right (> 48 or > 72 h, depending on where you look). Incidentally, surgeon was OK with doing THA 30 hours post last dose...

I'm pretty sure that the rate of post-operative delirium is the same wether the pt has GA vs Regional.

 

[IlDestriero]

As noted, the trend and situation is important.
Having said that,
Epidural- 75k
Spinal- 50k
The oncologists I work with will do spinals for intrathecal chemo at 15k, so we could probably go much lower.

 

[deleted171991]

The oncologists I work with will do spinals for intrathecal chemo at 15k, so we could probably go much lower.

What do various current guidelines say about the platelet numbers? Because you know some expert will end up quoting them, even if the number can mean nothing (such as in chronic ITP patients).

As others have suggested, it's tough to defend the risks >> benefits in our case. Any decision against some guideline needs to be balanced with a really difficult airway or significant medical pathology etc. Having the patient agree to the specific risks, even after discussing for 30 minutes, might not stand up when she later becomes paraplegic.

Where I trained, the number was 100 for most attendings, stable 90-ish in special situations for some. Don't remember ever going under 80.

 

[Noyac]

What do various current guidelines say about the platelet numbers? Because you know some expert will end up quoting them, even if the number can mean nothing (such as in chronic ITP patients).

As others have suggested, it's tough to defend the risks >> benefits in our case. Any decision against some guideline needs to be balanced with a really difficult airway or significant medical pathology etc. Having the patient agree to the specific risks, even after discussing for 30 minutes, might not stand up when she later becomes paraplegic.

Where I trained, the number was 100 for most attendings, stable 90-ish in special situations for some. Don't remember ever going under 80.

I think I would be ok at 60 (maybe even 50) for an ITP pt with good indication. I'd probably have close f/u for at least 12 hrs just to make me feel better about it.

 

[IlDestriero]

When I was a resident I believe our internal guidelines for a cut off was 80k for labor epidurals and 50k for a spinal, assuming it was stable. We didn't have guidelines for non OB neuraxial because the risk vs reward was too variable. A couple faculty were 100/75. I remember one attending laughing when I asked if we needed to transfuse a 74k for an elective labor epidural and we did it anyway. I'm not sure what his limit would be. I have seen the onco people transfuse platelets for 14, so they may have data to support 15k.

 

[BLADEMDA]

http://forums.studentdoctor.net/threads/ob-case.919678/#post-12611008

http://forums.studentdoctor.net/threads/ob-case.717008/#post-9512284


http://forums.studentdoctor.net/threads/routine-c-section.663595/#post-8624097

 

[BLADEMDA]

Depends on the case and the situation. There is no set number you must go by.
1) labor epidural at 2am- >100
2) thoracic epidural for bowel resection on a healthy guy >100
3) thoracic epidural for bowel resection on a resp cripple>80
4)spinal for THA in healthy pt>80
5) spinal for THA in a resp cripple >50
6) spinal for THA in a cardiac cripple on plavix, off for 5 days->80

I could go on but these are all moving targets and subject to change at my discretion on a case by case basis.

I agree with you here; but, I prefer Bilateral Subcostal/Standard TAP blocks as described by Hebbard for bowel resections as they are effective for postop pain without the concerns of the thoracic epidural.

 

[pgg]

http://forums.studentdoctor.net/threads/routine-c-section.663595/#post-8624097

I was just going to post a link to that thread.

 

[Noyac]

I agree with you here; but, I prefer Bilateral Subcostal/Standard TAP blocks as described by Hebbard for bowel resections as they are effective for postop pain without the concerns of the thoracic epidural.

True but only in those that are not candidates for epidural.