platelet # and neuraxial block

[m32b]

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51 yo alcoholic male falls down leaving a food shelter after thanksgiving dinner and ends up with a compound fracture of both left distal tibia and fibula...he was sober at the time....when the paramedics arrive they notice audible wheezing which escalates into a presumably full-blown asthma attack after they take a peek at the leg injury...bronchodilators were given at the scene and the patient shipped off to the er.

pertinent happenings in the er include: a negative spiral ct to r/o pe; unlabored breathing with continued wheezing and spo2 @ 91%; platelet count of 66k; coags otherwise normal; bleeding time slightly elevated; sight looked dry; full dinner three hours ago....needs to go semi-urgently for compound fracture repair.

after a long discussion with my attending, and subsequently the patient, we planned a spinal anesthetic after getting one platelet six-pack in, then infusing two more platelet six-packs over the course of the next few hours.

the spinal went in easily and the patient did very well with no neurological sequelae what so ever.


so, what's the lowest platelet count any of you have seen were a neuraxial technique was eventually used, and what was the outcome.

 

[militarymd]

around 50

 

[Noyac]

51 yo alcoholic male falls down leaving a food shelter after thanksgiving dinner and ends up with a compound fracture of both left distal tibia and fibula...he was sober at the time....when the paramedics arrive they notice audible wheezing which escalates into a presumably full-blown asthma attack after they take a peek at the leg injury...bronchodilators were given at the scene and the patient shipped off to the er.

pertinent happenings in the er include: a negative spiral ct to r/o pe; unlabored breathing with continued wheezing and spo2 @ 91%; platelet count of 66k; coags otherwise normal; bleeding time slightly elevated; sight looked dry; full dinner three hours ago....needs to go semi-urgently for compound fracture repair.

after a long discussion with my attending, and subsequently the patient, we planned a spinal anesthetic after getting one platelet six-pack in, then infusing two more platelet six-packs over the course of the next few hours.

the spinal went in easily and the patient did very well with no neurological sequelae what so ever.


so, what's the lowest platelet count any of you have seen were a neuraxial technique was eventually used, and what was the outcome.

Ther are case reports in the OB literature about epidurals being placed in pts with PLT counts from 20-50K. The plt counts were recognized after the epidural placement. No one would have placed the epidural had they known the count. I think anything under 70-80K needs to be weighed on a case by case basis and spinal is the way to go if you choose neuraxial. This case could have been done with a sciatic and FNB potentially and some sedation- Ketamine? I don't think I would have done the sciatic and FNB route but its possible.

 

[militarymd]

I've done a fem sciatic block for a colleague on a patient for a BKA...no sedation.

I personally would have put the lady to sleep, but my colleague was afraid to put her to sleep because her EF was barely double digit. And he wasn't confident with doing blocks.

 

[Noyac]

I've done a fem sciatic block for a colleague on a patient for a BKA...no sedation.

I personally would have put the lady to sleep, but my colleague was afraid to put her to sleep because her EF was barely double digit. And he wasn't confident with doing blocks.

Most BKA's are blocked before they come in (diabetic neuropathy)

 

[jetproppilot]

I think anything under 70-80K needs to be weighed on a case by case basis .

I concur.

I'm pro regional as you know, but I heir on the cautious side when bleeding diatheses are present or questionably present.

I wouldve put him to sleep too...you can take precautions for bronchospasm...B2 agonists, deep anesthesia before intubation, avoidance of histamine releasing agents, etc, even a cuppla mikes of epi IV if brocnhospasm becomes an issue.

I'd rather deal with potential bronchospasm issues than a potential clandestine neuraxial bleed.

But you guys did it "right" since it worked.