Poll: platelet count for spinal/epidural

[Lee123]

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What is the lowest absolute value you would do a spinal for a case. Trend is stable. No known reason for low count. Normal coags.

Without all the posturing, at what level will you just not do it. This means even if you would prefer NOT to do general (for whatever reasons: lung disease, bad airway, ...), what absolute count will you not perform a neuraxial technique?

 

[Bertelman]

70

 

[BLADEMDA]

What is the lowest absolute value you would do a spinal for a case. Trend is stable. No known reason for low count. Normal coags.

Without all the posturing, at what level will you just not do it. This means even if you would prefer NOT to do general (for whatever reasons: lung disease, bad airway, ...), what absolute count will you not perform a neuraxial technique?

It has been discussed in detail here with references. An Epidural is different than a single shot spinal.

We also have a PFA-100 analyzer avail these days with TEG or similar device.

In general, the number for an epidural is 65-75,000 while a spinal is 35-50,000. For me the 50,000 number for a spinal seems like a better cut-off. Theoretically 35,000 platelet count, a normal PFA and normal TEG could be your cut-off but I've never gone below 50K in clinical practice...Yet.

http://www.anesthesia-analgesia.org/content/108/5/1603.full


Maybe PGG can find the previous threads on this topic

 

[BLADEMDA]

What is the lowest absolute value you would do a spinal for a case. Trend is stable. No known reason for low count. Normal coags.

Without all the posturing, at what level will you just not do it. This means even if you would prefer NOT to do general (for whatever reasons: lung disease, bad airway, ...), what absolute count will you not perform a neuraxial technique?

http://forums.studentdoctor.net/showthread.php?t=663595&highlight=platelets

 

[Lee123]

50k is low for me.
Was there a reason you didn't want to do GA for that spinal with the plts 50k?

 

[Idiopathic]

in a vacuum, 50k is my cut off for spinal, although all scenarios are different

 

[IlDestriero]

Epidural 75.
Spinal 45.
Oncology will do IT chemo at 15k.😱

 

[Planktonmd]

100,000 for any neuraxial injection.

 

[rsgillmd]

If I absolutely did not want to do general, and everything else was OK, I'd probably be willing to go as low as 50 K for a spinal. Someone in whom the spinal/CSE may be difficult, I'd say 80 K.

Usually anything below 80 K, I get uneasy feelings about sticking the back.

Lots of factors to consider obviously, but if you are pushing me for numbers in an ideal setting for an unnamed procedure, those are mine.

 

[BLADEMDA]

Click on image to view larger version.

 

[BLADEMDA]

Anesthetic Management of Seven Deliveries in Three Sisters with the May-Hegglin Anomaly




Click on image to view larger version.



http://www.anesthesia-analgesia.org/content/108/5/1603.full


Brigham and Women's Hospital, Boston

 

[BLADEMDA]

If I absolutely did not want to do general, and everything else was OK, I'd probably be willing to go as low as 50 K for a spinal. Someone in whom the spinal/CSE may be difficult, I'd say 80 K.

Usually anything below 80 K, I get uneasy feelings about sticking the back.

Lots of factors to consider obviously, but if you are pushing me for numbers in an ideal setting for an unnamed procedure, those are mine.

We are pretty close. I've done a few Epidurals at 65,000 with normal PFA-100 (repeat platelet count stable, no other medical history).

I get uneasy for any epidural less than 75,000. I will go as low as 50,000 for a non cutting needle single shot spinal (again stable platelet count, healthy, no other issues)

 

[BLADEMDA]

Platelet Function Testing: PFA-100




Introduction


The PFA-100 is a system for analysing platelet function in which citrated whole blood is aspirated at high shear rates through disposable cartridges containing an aperture within a membrane coated with either collagen and epinephrine (CEPI) or collagen and ADP (CADP). These agonists induce platelet adhesion, activation and aggregation leading to rapid occlusion of the aperture and cessation of blood flow termed the closure time (CT). This LINK will take you to an animation that will explain this process in more detail.

Advantages of the PFA-100 include:Only small volumes of citrated venous blood [800µL) are needed and so the test is useful for investigating platelet function in children.Can be used by non-skilled personnel and is both rapid and automatedThe PFA-100 was designed as a screen to detect problems with primary haemostasis and in part to replace the bleeding time and in this respect it is better standardised.Measurement of platelet function at high shear [physiological] rates whereas LTA measures platelet function at low shear rates i.e. less physiological.Relatively insensitive to clotting factor deficienciesHigh negative predictive value – i.e. if the PFA-100 gives a normal result then with some exceptions primary haemostasis is intact [Exceptions: SPD, Primary Secretion Defects, mild Type 1 VWD]

 

[lobelsteve]

Anyone transfuse platelets for epidural anesthesia for Ortho cases?

 

[BLADEMDA]

Anyone transfuse platelets for epidural anesthesia for Ortho cases?

I have transfused platelets one time in my career to do a spinal. The patient, 90 years old and demented, had his power of attorney (R.N. daughter) demand a spinal. Of course, I agreed to the SAB but only if her Dad got platelets and FFP. (INR up, PLTs low). She actually delayed the case so these could be given to her Father.

These days we do have more lab tests available to determine if the platelets work and if the Plavix is still present; still, in private practice I'm only willing to stick my neck out so far.




Now, for the first time there is a simple and reliable wayto test for Plavix response. VerifyNow™ P2Y12 is a fast, easy to perform bloodtest specifically designed to measure the effects of Plavix on platelets, theblood cells primarily responsible for clotting. Inhibiting the function ofplatelets is how Plavix exerts its cardioprotective effects.

 

[Planktonmd]

unfortunately PFA has no clinical value in our business, and it was not endorsed by any one in anesthesia including ASRA.
I mean if the PFA is normal we don't know if this means a neuraxial injection is safe and if the PFA is abnormal we don't know if the neuraxial in not safe!
it is basically useless to us.

Platelet Function Testing: PFA-100




Introduction


The PFA-100 is a system for analysing platelet function in which citrated whole blood is aspirated at high shear rates through disposable cartridges containing an aperture within a membrane coated with either collagen and epinephrine (CEPI) or collagen and ADP (CADP). These agonists induce platelet adhesion, activation and aggregation leading to rapid occlusion of the aperture and cessation of blood flow termed the closure time (CT). This LINK will take you to an animation that will explain this process in more detail.

Advantages of the PFA-100 include:Only small volumes of citrated venous blood [800µL) are needed and so the test is useful for investigating platelet function in children.Can be used by non-skilled personnel and is both rapid and automatedThe PFA-100 was designed as a screen to detect problems with primary haemostasis and in part to replace the bleeding time and in this respect it is better standardised.Measurement of platelet function at high shear [physiological] rates whereas LTA measures platelet function at low shear rates i.e. less physiological.Relatively insensitive to clotting factor deficienciesHigh negative predictive value – i.e. if the PFA-100 gives a normal result then with some exceptions primary haemostasis is intact [Exceptions: SPD, Primary Secretion Defects, mild Type 1 VWD]

 

[Planktonmd]

Anyone transfuse platelets for epidural anesthesia for Ortho cases?

Not a good idea in my opinion.
The indication is not good enough to justify transfusing a very expensive blood product, and if the cause of the thrombocytopenia is not treated we will find ourselves with a thrombocytopenic patient with an epidural catheter later which is a complicated situation.
If the patient has a low platelet number or dysfunctional platelets they can get some other regional technique but not an epidural.

 

[BLADEMDA]

Anesth Analg. 2007 Feb;104(2):416-20.
Hemostatic function in healthy pregnant and preeclamptic women: an assessment using the platelet function analyzer (PFA-100) and thromboelastograph.

Davies JR, Fernando R, Hallworth SP.
Source

Department of Anesthesia, Royal Free Hospital, Pond St., London, United Kingdom.

Abstract

BACKGROUND:

The PFA-100 is a point-of-care platelet function analyzer which measures the speed of formation of a platelet plug in vitro, expressed as closure time (CT) in seconds. This device could potentially be used to assess primary hemostasis prior to regional anesthesia. In this prospective, observational study we sought to establish 95% reference intervals for PFA-100 and Thromboelastograph (TEG) values for our normal pregnant population, before comparing the PFA and TEG in measuring platelet function in preeclamptic and healthy pregnant women at term, using confidence interval analysis and analysis of variance.
METHODS:

Routine hematologic and coagulation tests were performed along with von Willebrand Factor, CT, and TEG measurements. Results are expressed as mean (sd).
RESULTS:

Increased severity of preeclampsia was associated with increasing prolongation of CT, even in the presence of normal platelet counts. In severe preeclampsia, the PFA-100 CT (mean (sd): 155 (65) s) exceeded the 95% reference interval of the control group (70-139 s). In contrast, TEG maximum amplitude (MA) in severe preeclampsia (mean (sd): 71 (8) mm) remained within the 95% reference interval for MA in normal pregnancy (64-82 mm).
CONCLUSION:

We conclude that impairment of primary hemostatic function with increasing severity of preeclampsia was recorded by the PFA-100 but not the TEG.

 

[BLADEMDA]

The PFA 100 MAY be usfeful in preeclampsia and type 1 VW disease.


http://www.obstetanesthesia.com/article/S0959-289X(07)00053-2/abstract

 

[BLADEMDA]

Am J Clin Pathol. 2005 May;123(5):772-7.
Platelet dysfunction in primary thrombocythemia using the platelet function analyzer, PFA-100.

Cesar JM, de Miguel D, García Avello A, Burgaleta C.
Source

Department of Hematology, Hospital Ramón y Cajal, Madrid, Spain.

Abstract

We measured platelet function by standard aggregometric tests and by the PFA-100 (Dade Behring, Newark, DE) in samples from 55 patients with primary thrombocythemia (PT) and 26 healthy volunteers. Platelet function was evaluated in platelet-rich plasma by aggregation tests. PFA-100 studies (closure time) were performed in citrated whole blood using collagen-adenosine diphosphate (ADP) and collagen-epinephrine cartridges. Plasma levels of von Willebrand factor (vWF) also were measured. The mean +/- SD closure time for patients vs volunteers for the collagen-epinephrine cartridge was prolonged (210.8 +/- 62.2 vs 118.1 +/- 19.6 seconds; P < .001); results were abnormal for 38 patients (69%). Results with the collagen-ADP cartridge also were abnormal in patients (134.3 +/- 58.4 seconds) vs volunteers (87.3 +/- 15.6 seconds; P < .001); closure time was prolonged in 23 patients (42%). A decreased response to epinephrine (38.4% +/- 34.2% vs 82.5% +/- 10.3%; P < .001), the main defect detected by platelet aggregation tests, affected 32 patients (58%). Platelet response to collagen also was abnormal (52.0% +/- 34.6% vs 86.0% +/- 10.1%; P < .01) but affected only 21 patients (38%). vWF levels for patients were normal. The results seem to confirm that platelet function in patients with PT is abnormal and show that platelet function can be assessed by an easy, reproducible, and sensitive method, the PFA-100. Closure time usually was prolonged; this feature could be applied in the diagnosis of PT.

 

[BLADEMDA]

Not a good idea in my opinion.
The indication is not good enough to justify transfusing a very expensive blood product, and if the cause of the thrombocytopenia is not treated we will find ourselves with a thrombocytopenic patient with an epidural catheter later which is a complicated situation.
If the patient has a low platelet number or dysfunctional platelets they can get some other regional technique but not an epidural.

J Thromb Haemost. 2006 Feb;4(2):312-9.
Platelet function analyzer (PFA)-100 closure time in the evaluation of platelet disorders and platelet function.

Hayward CP, Harrison P, Cattaneo M, Ortel TL, Rao AK; Platelet Physiology Subcommittee of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis.
Source

McMaster University and the Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada. [email protected]

Abstract

BACKGROUND:

Closure time (CT), measured by platelet function analyzer (PFA-100) device, is now available to the clinical laboratory as a possible alternative or supplement to the bleeding time test.
AIM:

On behalf of the Platelet Physiology Subcommittee of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis (ISTH-SSC), a working Group was formed to review and make recommendations on the use of the PFA-100 CT in the evaluation of platelet function within the clinical laboratory.
METHODS:

The Medline database was searched to review the published information on the PFA-100 CT in the evaluation of platelet disorders and platelet function. This information, and expert opinion, was used to prepare a report and generate consensus recommendations.
RESULTS:

Although the PFA-100 CT is abnormal in some forms of platelet disorders, the test does not have sufficient sensitivity or specificity to be used as a screening tool for platelet disorders. A role of the PFA-100 CT in therapeutic monitoring of platelet function remains to be established.
CONCLUSIONS:

The PFA-100 closure time should be considered optional in the evaluation of platelet disorders and function, and its use in therapeutic monitoring of platelet function is currently best restricted to research studies and prospective clinical trials.

 

[Lee123]

Not a good idea in my opinion.
The indication is not good enough to justify transfusing a very expensive blood product, and if the cause of the thrombocytopenia is not treated we will find ourselves with a thrombocytopenic patient with an epidural catheter later which is a complicated situation.
If the patient has a low platelet number or dysfunctional platelets they can get some other regional technique but not an epidural.

I agree. I do not give FFP or platelets to normalize values to give an epidural or spinal. The underlying problem still exists. If you are doing an epidural you will have to deal with an indwelling catheter and taking it out at some point.

 

[BLADEMDA]

I agree. I do not give FFP or platelets to normalize values to give an epidural or spinal. The underlying problem still exists. If you are doing an epidural you will have to deal with an indwelling catheter and taking it out at some point.

Every patient can get a General. Gas or TIVA. They may not survive for long but everyone can get a GA of some sort.

The role for our transfusing FFP or Platelets to do Regional makes little sense. Just skip the Neuraxial block and do a PNB like a Sciatic/Femoral. I've done those on patients with increased INR and or off plavix for just 3-5 days. The use of U/S allows more PNBs under less than ideal conditions (I disagree with ASRA here in treating every PNB like a Neuraxial)

 

[lobelsteve]

The case I was thinking of was SCS. Leads in and up from T12-L1 to T8. No removal of catheter or leads. But a lot bigger than a catheter. That's why I wanted plt in for baseline 65k. Had fusion done with plt Tx.