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Thrombocytopenia

militarymd

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    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.
     

    VentdependenT

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      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.
       
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      bullard

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        VentdependenT said:
        Keep in mind im a lowly friggen CA-1. Go easy on me peeps.

        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.
         

        zippy2u

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          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
           

          jetproppilot

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            militarymd said:
            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.

            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.
             

            Tenesma

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              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
               

              militarymd

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                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.
                 

                militarymd

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                  Annette said:
                  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


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

                  Noyac

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                    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.
                     

                    Annette

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                      militarymd said:
                      I think that is only for ITP...right?

                      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.
                       

                      militarymd

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                        Annette said:
                        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.


                        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.
                         
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