Transfusing platelets for epidural placement in labor

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Dinkyconductor

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Personally, I don't have an absolute cutoff value for platelet count to place a labor epidural.

But, let's say a patient came in with gestational thrombocytopenia and platelets below your comfort level, say, 52,000. I would be hesitant to place one regardless of the clinical history. Let's assume the patient doesn't have HELLP or DIC, it's just gestational thrombocytopenia.

In this case, would you
-Put her on a PCA
or...
-Transfuse platelets to bring her platelets up closer to normal, then place an epidural?

We have one obstetrician who routinely orders platelets on all his patients with counts below 100,000 before they even call us.

You could argue that the risk of transfusion of blood products is too great simply for improved labor analgesia, but some of our obstetricians would much prefer their patients have epidurals. I've tried to look for some practice guidelines on this, but haven't found any.

Anyone have any thoughts?
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I'd just ask the patient after presentig risks/benefits of transfusion for epidural. I she's OK, signs consent and that's what she wants then you can transfuse and then place epidural.
 
Dinkyconductor said:
You could argue that the risk of transfusion of blood products is too great simply for improved labor analgesia, but some of our obstetricians would much prefer their patients have epidurals.

Anyone have any thoughts?
Click to expand...

Being on OB right now I can tell you that for many patients "improved labor anesthesia" is no small thing.
 
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Honestly, I've never heard of doing such a thing, and can't imagine that we'd even consider it.
 
jwk said:
Honestly, I've never heard of doing such a thing, and can't imagine that we'd even consider it.
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+1.

One exception-storage pool disorder where the patient consults a hematologist before hand and they give the thumbs up for an epidural after a platelet transfusion.
 
Exposing someone to blood products for an elective procedure................I'll pass and so will my friends.:)

PCA or Nubain for Labor, GA for the section, no litigation for anyone

Plus at our institution, we dont have "extra" platlets lying around, I'll save em for the cancer and trauma patients.
 
Dinkyconductor said:
Personally, I don't have an absolute cutoff value for platelet count to place a labor epidural.

But, let's say a patient came in with gestational thrombocytopenia and platelets below your comfort level, say, 52,000. I would be hesitant to place one regardless of the clinical history. Let's assume the patient doesn't have HELLP or DIC, it's just gestational thrombocytopenia.
Click to expand...

50K is my spinal cutoff for gestational thrombocytopenia (ie after appropriate labs ruling out other causes of thrombocytopenia). She can have a labor spinal at that level without transfusion.

My transfusion threshold for parturients is 20K for a vaginal delivery, 50K for a section (GA), and 75K for a section (regional).

I wouldn't ordinarily transfuse platelets for an elective labor spinal or epidural. Transfusion risk is low but nonzero, and platelets are a scarce enough resource that using them for an elective procedure when alternatives exist (PRN IV meds, PCA) just doesn't seem right to me. I don't think it's too unreasonable, but it's not something I'd volunteer to offer.

If the OB had strong feelings about it, or if the patient had seen a hematologist prior and had it all planned out with the hematologist's blessing, I'd probably go along with it.
 
Just as a data point, the peds oncologists are happy to do an LP and IT chemotherapy with a platelet count >15K.
I use 70K for a labor epidural, and 50K for spinal. Would I do 40 or 45k? Probably, if the choice was GA vs transfusion, though I would bet that the OBs would want to transfuse to over 50K for a c/s. I would strongly suggest it.
 
Magnus67 said:
Exposing someone to blood products for an elective procedure................I'll pass and so will my friends.:)

PCA or Nubain for Labor, GA for the section, no litigation for anyone

Plus at our institution, we dont have "extra" platlets lying around, I'll save em for the cancer and trauma patients.
Click to expand...

uhh...really?
 
Another question could be what is the trend of her platelets. If the patient has a plt count of 100,000 and 1 week later her count is 65,000 I would not be comfortable placing a labor epidural. Another backside attack thinking is when do you pull the epidural. Most vaginal deliverys loose about 500ml of blood, by how much does the platelet count fall after delivery? Now you have an epidural in a patient with a platelet count of 30,000 whom has just delivered and you need to pull the catheter and possibly dislodge the formed clot. I would check the trend place the catheter if the count has been steadily 50,000 or above and place the epidural.
 
OK, so it sounds as though most feel that the risk of a transfusion reaction outweighs the benefits of improved labor analgesia.

That was my general feeling as well, I just hope I'm able to convince the patient and OB to see it my way when it happens.

Thanks, all.
 
yes but factor in airway difficulty, patient desire for labor analgesia and any other comorbid conditions and you may find that you look at specific cases differently. I have transfused platlets to place an epidural in a dramatically challenging patient, so I wont say that it shouldnt be done.
 
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Dinkyconductor said:
OK, so it sounds as though most feel that the risk of a transfusion reaction outweighs the benefits of improved labor analgesia.

That was my general feeling as well, I just hope I'm able to convince the patient and OB to see it my way when it happens.

Thanks, all.
Click to expand...

Although obviously some moms would argue, a labor epidural is an elective procedure. C-Sections can indeed be done with general anesthesia, and there have been several threads on this forum about the real vs perceived risk of GA for sections. An epidural in a clearly thrombocytopenic patient vs a CS under general? I'll take the general CS any day.
 
what about a spinal in a 4'11" 260 pound patient with pierre robin who refuses awake intubation. platelets are 40,000 and hematology is calling it ITP
 
Idiopathic said:
what about a spinal in a 4'11" 260 pound patient with pierre robin who refuses awake intubation. platelets are 40,000 and hematology is calling it ITP
Click to expand...

I'll bundle em up and ship em to you! ;)
 
Idiopathic said:
what about a spinal in a 4'11" 260 pound patient with pierre robin who refuses awake intubation. platelets are 40,000 and hematology is calling it ITP
Click to expand...

Will there be simultaneous primary power and hospital generator failures too? :)


I'd be giving platelets for a section if she was at 40K anyway, so the dilemma here really boils down to how urgent the section is (and if she can be talked into un-refusing AFOI).

If it's a routine section I'd just give platelets (possibly after IVIg if it's ITP) and do a spinal.

If urgent/emergent you're in the no-perfect-answer oral board nightmare.
  • Unless she JUST rolled in the door in extremis then presumably you've had at least some period of time during which you knew a potential bad airway, thrombocytopenic c-section was brewing. This time would've been well spent getting IVIg and platelets into her, even if a section wasn't on the radar yet; crisis averted.
  • If it's emergent, bully her into accepting awake intubation with scary talk of a section done under local. :) There comes a point at which we can't save patients from themselves, and sticking your own neck out isn't a solution. A paralyzed patient isn't going to be defensible in court, just because the patient was afraid of an AFOI and the OB was doing some bug-eyed anxious hurryup dance. The peds oncologist who does taps at 15K won't be your expert witness.
 
Jay K said:
I'd just ask the patient after presentig risks/benefits of transfusion for epidural. I she's OK, signs consent and that's what she wants then you can transfuse and then place epidural.
Click to expand...

I'm not sure whether any patient, much less one writhing in pain, has the ability to weigh the subtle pros/cons, both individual and societal, of my transfusing her a unit of platelet for a labor epidural.
 
well ill just say that i was presented with almost that exact situation on call one night, started on steroids no improvement in platelet count. sent platelet function assay, essentially normal, my relief transfused platelets as spinal was going in.

i dont think i would have offered her an epidural under any circumstances however, just wouldnt fell comfortable having a catheter in for any extended period of time.
 
im also not sure of the emergent management. lets say patient absolutely refuses AFI and you wont do neuraxial. ketamine and local acceptable? honestly for the boards id just offer local no sedation or AFI, like you mentioned.
 
The problem with transfusing platelets to put in an epidural is how do you get the epidural out?

Let's say 6-10 hours after you put it in, she delivers her baby. Those platelets you transfused are already gone. She's also used up a lot of platelets as her body is stopping bleeding from the trauma of the delivery. If you repeat a platelet count after delivery, it's going to be lower than it was before you put the epidural in.

Now what do you do? Transfuse 3 units of platelets and then pull it out?

I am a firm believer that if the platelet count is too low for you to put an epidural in (whatever your cutoff is), then you shouldn't tranfuse just to put it in. It's an elective procedure and platelets have a relatively high risk of transfusion reaction.

Now if it is too perform a spinal for c-section in a patient for whom avoiding GA is desireable, that's a different story.
 
epidural man said:
Of course I do...thanks for asking.

Remifentanil PCAs work really really well. I mean, really really well.

In fact, when I see it, I often think - damn, why am I even putting epidurals in?
Click to expand...

Do you do anything special when setting up remi PCAs?

I've had trouble with the patient learning curve for timing the button hits, mainly because of the short duration of contractions and the lag between a button hit and onset of that dose. Sort of mitigated by running a basal infusion and using the ER-special Y tubing at the angiocath with the PCA on one and a LR pump on the other. But certainly higher maintenance than an epidural, and it always freaked the hell out of the nurses. I haven't done one in a long long time.
 
Are you running a basal + PCA? what are your dosages for infusion/PCA? What's your concentration in the bag?


epidural man said:
Of course I do...thanks for asking.

Remifentanil PCAs work really really well. I mean, really really well.

In fact, when I see it, I often think - damn, why am I even putting epidurals in?
Click to expand...
 
pencan said:
Are you running a basal + PCA? what are your dosages for infusion/PCA? What's your concentration in the bag?
Click to expand...

Our starting numbers were
- 0.2 mcg/kg boluses
- 1 minute lockout
- 0.02 mcg/kg/min basal rate

Worked but was a hassle and there were logistic and practical issues. Don't remember the concentration. I don't think I've done one since I was a resident.
 
Our stupid PCA pumps only allow a minimum lockout of 5 min, so while I love remi, they do not work that well for us. I have used them, and had to up the infusion rate. The need for them are so rare I have not convinced administration to get pumps without this 5 min lockout floor yet.
 
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