1. The SDN iPhone App is back and free through November! Get it today and please post a review on the App Store!
    Dismiss Notice
  2. Dismiss Notice

Thrombocytopenia

Discussion in 'Anesthesiology' started by militarymd, Nov 23, 2005.

  1. militarymd

    militarymd SDN Angel
    10+ Year Member

    Joined:
    Dec 17, 2003
    Messages:
    5,889
    Likes Received:
    15
    Status:
    Attending Physician
    We had a 45 year old male coming to the OR today for should arthroscopy. His PMHx is significant for Hep C with cirrhosis and splenomegaly and persistent mild thrombocytopenia ~ 85,000 .

    Heme/onc consults says to give 1 unit pheresed platelet before case and 1 unit after case to prevent bleeding complication.

    Plt count today was 45...and became 55 after 1 unit of the pheresed platelet.

    Surgeon is wondering if it was OK to do the case.

    What would everyone say? PT/PTT were normal.

    I discussed the case with the surgeon and arrrived at a way to proceed that made him very happy.
     
  2. Note: SDN Members do not see this ad.

  3. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    I'd ask the surgeon on the risk of bleeding with this particular pt. A knee arthroscopy typically is a very low blood loss procedure.

    With counts between 50-100K its at our discretion in regards to bleeding risk. I think it would be wise to hang another 6 pack, throw a tournicate on the thigh, and go for it.

    Keep in mind im a lowly friggen CA-1. Go easy on me peeps.
     
  4. Idiopathic

    Idiopathic Newly Minted
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Apr 21, 2003
    Messages:
    8,362
    Likes Received:
    17
    Status:
    Attending Physician
    Bleeding time normal?


    Even if it is, I dont see why you wouldnt administer more platelets, if only for treating the lab value.
     
  5. bullard

    bullard Senior Member
    10+ Year Member

    Joined:
    Oct 15, 2005
    Messages:
    422
    Likes Received:
    1
    Status:
    Attending Physician
    Well, that's no excuse for misreading the case -- it's a shoulder arthroscopy.

    :) Just giving you a hard time.

    Anyway, as an even lowlier MS4, here's my (probably incorrect) thoughts. ASA guidelines say you should transfused below plt count of 50. That's already been done. Shoulder arthroscopy shouldn't be excessive in terms of blood loss and fairly quick. No need for transfusion afterward because you're not operating on them -- spontaneous bleeding occurs at 10-20. So just proceed with GA with LMA.
     
  6. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    Doh!

    Bah, just throw a tournicate on the thigh anyways.
     
  7. zippy2u

    zippy2u Senior Member
    5+ Year Member

    Joined:
    Feb 19, 2005
    Messages:
    501
    Likes Received:
    5
    Do what the heme/onc guy told you to do and proceed with interscalene block with GETA. It seems chronic in nature and his body has adjusted to the low platelets. PT not elevated so liver dz ain't that bad. ----Zippy
     
  8. jetproppilot

    jetproppilot Turboprop Driver
    10+ Year Member

    Joined:
    Mar 12, 2005
    Messages:
    5,858
    Likes Received:
    105
    No problem. Youre not operating on the aorta.

    Additionally, with platelet count 55k, if you transfuse more platelets you'll make the number higher, and the surgeon may feel better, but it is unlikely to affect (effect? i can never remember which one) case outcome.
    You'd be surprised how good pedi ITP pts with counts of 20K do.

    BUT YOU WANNA BE JEDI WARRIOR?

    Tell the surgeon all the stuff you're gonna do below:

    1)order platelet qualitative assay which will give percentage of effective platelets. After the number comes back good, tell the surgeon you're more worried about the Cane's standings after losing to Georgia Tech than you are about having a perioperative problem.
    2)Have blood products ready just in case
    3) Keep MAP 70-75
    4)Avoid dilutional thrombocytopenia from iatrogenic crystalloid overindulgence.
     
  9. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    ask the orthopod to do the splenectomy first so that you can solve his consumption thrombocytopenia... then on to the shoulder arthroscopy... and double glove
     
  10. militarymd

    militarymd SDN Angel
    10+ Year Member

    Joined:
    Dec 17, 2003
    Messages:
    5,889
    Likes Received:
    15
    Status:
    Attending Physician
    The platelet assay shows normal platelets...just not enough. Here is the kicker, we only have one more unit of platelets left. The surgeon asks me should we proceed.

    Here is what I did.

    I ask him what kind of bleeding complications can you get in a worse case scenario from a shoulder arthroscopy. He describes essentially cosmetic type bleeding....ecchymoses and superficial trocar sight bleeding....no hemarthoses.

    So, we agreed that in the worse case...the bad outcome is not that bad.

    I recommended to him that we give 0.3 mcg/kg of ddavp (pubmed search temrs ddavp and cirrhosis)prior to incision and give the last unit of platelets near the conclusion of surgery.

    Both interventions serve to minimize risk of post-operative bleeding..incidence of which was unknown to me, the orthopod, and the heme/onc.

    Case proceeds uneventfully. Patient declines interscalene block.

    And yes, I sat on my butt in the preop area writing the orders for the ddavp, and a CRNA did the case...as my orthopods expected....I was available to give recommendations on how to assess and minimize the risk associated with a medical condition.

    An anesthetist did the case as directed.
     
  11. blocks

    5+ Year Member

    Joined:
    Apr 27, 2005
    Messages:
    222
    Likes Received:
    0


    :laugh:
     
  12. Annette

    Annette gainfully employed
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 24, 1999
    Messages:
    1,446
    Likes Received:
    3
    Status:
    Attending Physician
    You can also give Immunoglobulin the day or two prior to the case. I liked the qualitative assay answer as the risks of bleeding about 30 are pretty low.

    Effect- caused by something
    Affect- description of something- e.g., flat affect on a patient
     
  13. militarymd

    militarymd SDN Angel
    10+ Year Member

    Joined:
    Dec 17, 2003
    Messages:
    5,889
    Likes Received:
    15
    Status:
    Attending Physician

    I think that is only for ITP...right?
     
  14. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,611
    Likes Received:
    2,188
    Status:
    Attending Physician
    Some of my thoughts are:
    1. Platelets are not too low (for me).Ptelets become more functional during chronic thrombocytopenia and bleeding is not an issue. This is esp'ly true in ITP. In cirrhosis this may be different. I would check the albumin and if this is low consider vit K (most likely normal since coag's are normal) A TEG scan is a nice tool to use when deciding were the bleeding problem may be. Not always available however and some what difficult to read.
    2. Shoulder scopes are not nearly as painful as open shoulders in most surgeons hands. Interscalene blosk is optional and I would probably avoid it at least in the begining. You can add it after the case if pain is a real issue. But be careful with the amount of local in cirrhosis. If the protein is low then you have more unbound local and an intravascualr injection can go south fast. Just a thought and not a big concern but be aware.
    3. As Mil mentioned, keep the MAP down (70-80) I like 70 personally so the surgeon can see what he is doing and can see the little bleeders to bovie. When he is done there should be no bleeding except trocar sites.

    So basically I would do the case as is without a block and without a transfusion assuming the labs are fine. I would have the surgeon place a onQ pump (local infusion pump) duringthe case and have it run for 2 days.
     
  15. Annette

    Annette gainfully employed
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 24, 1999
    Messages:
    1,446
    Likes Received:
    3
    Status:
    Attending Physician
    Yep! Just testing you anesthesia types! ;) I realized I was wrong after I shut down my computer. I learned you could use immunoglobin when the surgeons were planning to repair the aorta on a patient with ITP, who also was fond of his drink- hence my slip.
     
  16. militarymd

    militarymd SDN Angel
    10+ Year Member

    Joined:
    Dec 17, 2003
    Messages:
    5,889
    Likes Received:
    15
    Status:
    Attending Physician

    I grew up in N. Canton. Almost came there for private practice......the foot of snow with the 19 degree temp you guys have right now is reminding me of my excellent decision to go to the south.
     
  17. beezar

    beezar Senior Member
    7+ Year Member

    Joined:
    Jan 31, 2002
    Messages:
    191
    Likes Received:
    1
    anyone with a good reference on ddavp use intraoperatively? indications, etc.
     
  18. militarymd

    militarymd SDN Angel
    10+ Year Member

    Joined:
    Dec 17, 2003
    Messages:
    5,889
    Likes Received:
    15
    Status:
    Attending Physician
    try this

    You will need to go to the library to get the article.
     

Share This Page