1. Irrational Exuberance: Component Therapy Before Bedside Procedures
Jeannie Callum, BA, MD, FRCPC, CTBS
Sunnybrook Health Sciences Centre
Associate Professor, University of Toronto

2. Outline 3 recent papers Bedside procedures and the evidence:
Central venous catheters
Liver biopsy
Thoracentesis & Paracentesis
Bronchoscopy &Transbronchial biopsy
Renal Biopsy
Epidural/Lumbar puncture

3. Mayo Clinic - January 2002 through February 2008
Incidence of bleeding after 15,181 percutaneous biopsies and the role of ASA Am J Radiology 2010; 194:
Mayo Clinic - January 2002 through February 2008
Solid organ percutaneous biopsies
5,832 Kidney biopsies
3,636 Liver biopsies
1,174 Lung biopsies
384 Pancreas biopsies
4,155 Other biospies

4. Local practice at the Mayo clinic:
Incidence of bleeding after 15,181 percutaneous biopsies and the role of ASA Am J Radiology 2010; 194:
Local practice at the Mayo clinic:
Platelets >50
INR<1.6
Primary endpoint was major bleeding within 3 months of the procedure
Major bleeding = RBC transfusion, interventional radiology procedure, operative procedure
Follow-up at 3 months was available for 95% of the patients

5. Incidence of bleeding after 15,181 percutaneous biopsies and the role of ASA Am J Radiology 2010; 194:
Of 15,181 biopsies, 70 bleeding complications (0.5%) within 3 months, including three deaths (3/15,181, 0.02%)
Of the 70 patients with bleeding compared with the remaining patients, the platelet count was lower (194 vs. 257; p <0.001) and the INR was higher (1.2 and 1.0; p < 0.001)
No statistically significant difference in the major bleeding complication rates was seen between patients who took aspirin (within 10 days) compared with those who did not (p = 0.34)

7. Large-bore tunneled central venous catheter insertion in patients with coagulopathy. Haas B, Chittams JL, and Trerotola SO. J Vasc Interv Radiol 2010; 21:
The Society of Interventional Radiology (SIR), recommend that one needs an INR of 1.5 and a platelet count of 50,000/µL for an ultrasound- guided line placement
Single center report from the University of Pennsylvania Medical Center
Reviewed the outcomes of 3,170 tunneled central venous catheter placements in 2,514 unique patients

8. All performed under ultrasound guidance
Large-bore tunneled central venous catheter insertion in patients with coagulopathy. Haas B, Chittams JL, and Trerotola SO. J Vasc Interv Radiol 2010; 21:
Their guidelines:
Plt count >25 and INR<2 (although some clinicians tolerated even more abnormal numbers)
All performed under ultrasound guidance
Patients excluded from the analysis if they had received FFP or platelets between their last set of laboratory values and the procedure
Objectives:
Primary-incidence of bleeding in first 24 hours
Secondary-incidence of infection and catheter failure

9. They had 27 complications out of 3,170 insertions (1 in 117)
Large-bore tunneled central venous catheter insertion in patients with coagulopathy. Haas B, Chittams JL, and Trerotola SO. J Vasc Interv Radiol 2010; 21:
567 were placed in patients with platelet counts below 50,000/µL and/or an INR>1.5
They had 27 complications out of 3,170 insertions (1 in 117)
3 of 567 patients with abnormal laboratory numbers developed complications, of which none were hemorrhagic (1 in 189)
3 bleeding complications (1 in 1057), all with platelet counts above 50,000/µL and INR<1.5

10. Large-bore tunneled central venous catheter insertion in patients with coagulopathy. Haas B, Chittams JL, and Trerotola SO. J Vasc Interv Radiol 2010; 21:
99 patients had platelet counts below 30 and 71 had INRs >1.9 at the time of the procedure, suggesting many of their clinicians feel comfortable doing these procedures with more abnormal laboratory values
The lowest platelet count was 3 and the highest INR was 3.8
Despite these very abnormal laboratory test results, the complication rate in this group with abnormal laboratory results was identical to that of patients with more normal laboratory numbers

11. Large-bore tunneled central venous catheter insertion in patients with coagulopathy. Haas B, Chittams JL, and Trerotola SO. J Vasc Interv Radiol 2010; 21:
If this institution had followed the Society of Interventional Radiology guidelines:
They would have needless transfused 300 patients platelets, 282 patients FFP, and 44 both products
This translates into approximately 344 adult doses of platelets and 1304 units of FFP administered needlessly

12. 28 ‘coagulopathic’ patients in Austin, Texas
Recombinant factor VIIa for the correction of coagulopathy before emergency craniotomy in blunt trauma patients J Trauma 2010; 68:
28 ‘coagulopathic’ patients in Austin, Texas
Aka borderline laboratory abnormalities (defined as an INR>1.3)
75% had subdural hematomas
Compared 14 patients that got r7a with the 14 that did not (Not randomized!) – 1.2 mg!
rFVIIa group was older (59 vs 41, p 0.04)
rFVIIa group was more likely to be on warfarin (57 vs. 14%, p 0.05)
no statistical difference in admission INR (rFVIIa 2.6 vs. no- rFVIIa 1.9, p 0.10)

13. There were no thromboembolic complications in either group
Recombinant factor VIIa for the correction of coagulopathy before emergency craniotomy in blunt trauma patients J Trauma 2010; 68:
There were no thromboembolic complications in either group
There were 7deaths (50%) in the rFVIIa group and 4 deaths (29%) in the no-rFVIIa group (p =0.22)

14. Recombinant factor VIIa for the correction of coagulopathy before emergency craniotomy in blunt trauma patients J Trauma 2010; 68:

15. Prothrombin complex concentrate vs rVIIa for reversal of coumarin anticoagulation
Dickneite G. Thrombosis Res 2006; Jul 12: Epub ahead of print

16. Prothrombin complex concentrate vs rVIIa for reversal of coumarin anticoagulation
Dickneite G. Thrombosis Res 2006; Jul 12: Epub ahead of print

17. Exploratory study on the reversal of warfarin with rFVIIa in healthy subjects Blood Epub April12, 2010
Bleeding Time (same results for blood loss) N
BT pre
BT post warf
BT post treatment
Placebo 24
18.7
29.5
26.3
40 ug/kg 12
20.7
32.3
28.9
80 ug/kg
18.6
31.9
27.7 PT N
PT pre
PT post warf
PT post treatment
Placebo 24
13.0
27.3
26.7
40 ug/kg 12
12.9
26.8
14.7
80 ug/kg
13.3
30.4
15.0

18. What is the evidence from systematic reviews?

19. INR and aPTT do NOT predict which patient will bleed Segal et al
INR and aPTT do NOT predict which patient will bleed Segal et al. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005;45:

20. Role of PT and aPTT in predicting post-operative hemorrhage
Eckman MH, Erban JK, Singh SK, Kao GS. Screening for the risk for bleeding or thrombosis. Ann Intern Med 2003; 138: W15-W24.
17 studies
Role of PT and aPTT in predicting post-operative hemorrhage
“For nonsurgical and surgical patients without synthetic liver dysfunction or a history of oral anticoagulant use, routine testing has no benefit in assessment of bleeding risk.”

21. Bleed
No Bleed
Rate
PT elevated 2
241
1 in 121
PT not elevated 23
1561
1 in 68
All Patients 25
1802
1 in 72

22. FFP given before a procedure will not correct an INR <2

23. The relationship between the INR and coagulation factors
60 ml/kg FFP = 4 L FFP
100 %
zone of normal
hemostasis
50 %
15 ml/kg FFP
30 %
zone of anticoagulation
INR 1
1.3
1.7
2.0
2.2
3.0

24. Effect of FFP on patients with INRs between <1.8
Abdel-Wahab OI, et al. Transfusion 2006; 46:

25. Stanworth et al. Is fresh frozen plasma clinically effective?
A systematic review of randomized controlled trials. Br J Haematol. 2004;126:
57 trials evaluated
Liver disease, cardiac surgery, warfarin-related hemorrhage, massive transfusion, prevention of IVH in infants, burns, etc.
…for most clinical situations, the RCT evidence base for the clinical use of FFP is limited…the strongest RCT evidence seems to indicate that the prophylactic use of FFP is not significantly or consistently effective across a range of different clinical settings.

26. Globally there is no evidence…
What about for specific procedures?

27. What is the evidence for specific procedures?
Bedside procedures and the evidence:
Central venous catheters
Liver biopsy
Thoracentesis & paracentesis
Bronchoscopy & transbronchial biopsy
Renal Biopsy
Epidural/Lumbar puncture

28. Central venous catheters
57 year old woman with AML needs a Hickman line insertion to commence chemotherapy today
Her INR is 1.9 and PTT 41 this morning – she has suspected mild DIC and vitamin K deficiency (not eating and on broad spectrum antibiotics)
Given iv vitamin K 10 mg iv this AM
Platelet count is 38
No active bleeding and no bleeding history
What would you request?

29. What do we know?
Bleeding complications relate to inadvertant puncture of the carotid or subclavian artery
Denys BG, et al. Circulation. 1993;87:
Vanherweghem JL, et al. Am J Nephrol. 1986;6:
Systematic review of complications of CVC insertion (jugular or subclavian) reported 48 episodes of pneumothorax and/or hemothorax after procedures (1.4%), although only one-third of the episodes were hemothorax (=0.5% risk of a hemothorax).
Ruesch S, et al. Crit Care Med. 2002;30:

30. What do we know?
A meta-analysis of 8 RCTs found that the use of Doppler ultrasound to guide line placement reduced the incidence of placement complications (OR 0.22, )
Randolph AG, et al. Crit Care Med. 1996;24:
Greater experience by the physician performing the CVC insertion reduces the risk of procedural complications
Sznajder JI, et al. Arch Intern Med. 1986;146:

31. Sunnybrook
All our lines are placed with ultrasound guidance by experienced interventional radiologists
0.5% x 0.22 = 0.11% (1 in 909 major bleed rate)

32. CVC insertion Foster PF, Moore LR, Sankary HN, et al
CVC insertion Foster PF, Moore LR, Sankary HN, et al. Central venous catheterization in patients with coagulopathy. Arch Surg. 1992;127:273-5.
202 CVC insertions performed on liver transplant patients with severe hemostatic abnormalities
No attempts were made to correct laboratory abnormalities before the procedure
Mean coagulation factor levels were 29% of normal (range=10-39%), mean PTT was 92 sec (range= seconds), mean platelet concentration was 47 (range=8- 79)
Despite these values and the lack of any pre-procedure therapy, no serious bleeding complications occurred

33. CVC insertion Doerfler ME, Kaufman B, Goldenberg AS
CVC insertion Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of hemostasis. Chest. 1996;110:185-8.
76 patients who received 104 central catheters
22 catheters were placed with platelet counts of , 30 catheters with counts of 20-50, and 11 with counts below 20
13 percent of patients had a combination of thrombocytopenia and prolongation of the PT/PTT
None were given transfusions of platelets or FFP before the procedure
None had serious complications, intrathoracic bleeding, or an unexpected drop in hematocrit

34. More evidence
115 patients undergoing CVC insertion with thrombocytopenia (mean 24,000/µL) found no difference in the platelet counts of patients with and without bleeding complications.
Barrera R, et al. Cancer. 1996; 78:
388 consecutive catheterizations in patients with heme malignancies with thrombocytopenia present in 28% of patients (32 patients 50-99, 41 patients 30-49, and 36 patients <30) and abnormal coags were present in 19%
Bleeding occurred after line insertion in only 5 cases (1 in 78 patients) and all 5 patients had platelet counts below 30,000/µL.
No difference in bleeding rates between patients with normal and abN coags
Nosari AM, et al. Leuk Lymph. 2008;49:

35. More evidence Petersen GA
More evidence Petersen GA. Does systemic anticoagulation increase the risk of internal jugular vein cannulation? (letter) Anesthesiology. 1991;75:1124.
516 consecutive patients with internal jugular lines before cardiac surgery
252 (49%) were anticoagulated with heparin
An observer who was unaware of the anticoagulation status of each patient recorded the presence of an insertion site hematoma
Of the 22 hematomas that occurred
13 were in anticoagulated patients
9 were in non-anticoagulated persons
This difference was not significant

36. More evidence Fisher NC, et al. Intensive Care Med. 1999;25:481-5.
658 CVC line insertions
Median INR was 2.4 (1–16) (580 cases >1.5)
Median platelet count was 81 (9 – 1,088) (531 <150)
In 453 cases both abnormalities were present
Patients were not given any pre-procedure transfusion of FFP or platelets
1patient, with near normal tests, developed a hemothorax after inadvertent puncture of the subclavian artery
There were no other major hemorrhagic complications

37. More evidence Hass B, et al. J Vasc Interv Radiol 2010; 21: 212-217.
Of 3188 tunneled CVCs placed:
428 had platelet counts <50 (down to 3)
361 had INR>1.5 (up to 3.8)
They excluded any patient that had been transfused product between the last reading and the procedure
3 had bleeding complications
None had platelet counts <50 or INR>1.5

38. Bottom line No evidence for any pre-procedure component therapy
Based on the evidence, the most conservation stance you could take would be to require a platelet count in excess of 25-30
There is no INR above which patients appear to be at higher risk

39. Liver biopsy
45 year old with cryptogenic cirrhosis needs a diagnostic percutaneous liver biopsy (with ultrasound guidance)
His INR is 2.2, PTT 48, and platelet count 48
He has no bleeding history
What would you order before the procedure?

40. Liver Biopsy
The perfect patient population to test NOT giving prophylactic transfusions:
Patients often have abnormal laboratory tests of coagulation
They are often thrombocytopenic
They have multiple other derangements of hemostasis
You can’t compress the liver if it bleeds

41. Piccinino F, Sagnelli E, Pasquale G, et al
Piccinino F, Sagnelli E, Pasquale G, et al. Complications following percutaneous liver biopsy. A multicentre retrospective study on 68,276 biopsies. J of Heaptology 1986; 2:
A very large series of 68,276 percutaneous biopsies published in 1986 found that major bleeding occurred in only 42 patients.
1 in 1626 patients

42. Ewe K. Bleeding after liver biopsy does not correlate with indices of peripheral coagulation. Dig Dis Sci 1981;26:
200 consecutive patients undergoing liver biopsy with laproscopic ‘observation’ for bleeding
No degree of abnormal lab tests warranted pre- procedure therapy at this institution
There was no correlation of liver bleeding time and laboratory test results
Even patients with INR>3 and platelets<50 did not bleed more than patients with ‘better’ test results

43. Random distribution

44. 9000 liver biopsies performed over a 21 year period
McGill DB, et al. A 21-year experience with major hemorrhage after percutaneous liver biopsy. Gastroenterology. 1990;99:
9000 liver biopsies performed over a 21 year period
Patients had pre-procedure INR’s up to 1.8 and platelet counts as low as 55
Post-biopsy hemorrhage occurred in 32 patients
The lab values did not differ between the 32 with substantial bleeding and the rest of the patients

45. Makris M, et al. A prospective investigation of the relationship between hemorrhagic complications of percutaneous needle biopsy of the liver and coagulation screening tests. Br J Haematol. (abstract) 1992;81:51.
104 patients undergoing liver biopsy who were screened for bleeding complications with post- procedure CT scans
Half of the patients had abnormal coagulation tests pre-procedure including numerous patients with PT values corresponding to INRs > 2.0, PTTs >50, and platelet counts as low as 50
Two patients bled post-procedure and both of these had normal pre-procedure coagulation values

46. Bottom line Bleeding is very rare
There is no data to support the notion that patients with abnormal lab values will bleed more than patients with normal lab values at the time of percutaneous liver biopsy

47. Thoracentesis & Paracentesis
67 year old EtOHic male is admitted through the ER with query spontaneous bacterial peritonitis resulting in sepsis
INR 5
Platelet count 23
He needs a diagnostic peritoneal tap
What would you give him prior to the procedure?

48. Pache I, and Bilodeau M. Severe hemorrhage following abdominal paracentesis for ascites in patients with liver disease. Ailment Pharmacol Ther. 2005;21:525-9.
Severe hemorrhage following abdominal paracentesis is exceptionally rare
A recent large series of 4729 patients observing severe hemorrhage in only 0.19% of patients
1 in 525 patients

49. None of the patients was given prophylactic components
McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 1991;31:
A review of outcomes in 608 consecutive procedures (391 paracenteses, 207 thoracenteses, and 10 both)
None of the patients was given prophylactic components
Bleeding complications occurred in 0.2%
No difference between normal PT/PTT compared with those with a prolonged PT/PTT
No differences between platelet counts above 100 compared with those with counts of or 25-50

50. There was no significant bleeding in any patient
Grabau CM, et al. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004;40:484-8.
1,100 paracenteses at a center where no degree of thrombocytopenia or pre-procedure coagulation test result was deemed unsafe for the procedure
All procedures were performed without ultrasound guidance and without the transfusion of platelets or plasma
The lowest platelet count was 19 (IQR 42-56) and the highest INR was 8.7 (IQR )
There was no significant bleeding in any patient

51. Guidelines
In the 2009 American Association for the Study of Liver Diseases Practice Guidelines on the management of adult patients with ascites due to cirrhosis, the guideline committee recommended that “Because bleeding is sufficiently uncommon, the routine prophylactic use of fresh frozen plasma or platelets before paracentesis is not recommended.”
Runyon BA. AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49:

52. Transbronchial biopsy
68 year old man on ASA for a bare metal stent placed 1 year ago is booked for bronchoscopy and transbronchial biopsy
He has a history of 2 TIAs
His platelet count is normal
Would you stop his ASA?

53. Bronchoscopy and Biopsy
Complications at the time of bronchoscopy are rare, in one large report a major complication was seen in only 0.08% of 24,521 procedures
Complications are higher with transbronchial biopsy, estimated in one large series at approximately 2% for all patients
Credle W, Smiddy J, and Gruber B. Deaths and complications of fiberoptic bronchoscopy. Am Rev Respir Dis 1974; 109:
Cordasco EM Jr, Mehta AC, and Ahmad M. Bronchoscopically induced bleeding. A summary of nine years’ Cleveland Clinic experience and review of the literature. Chest. 1991;100:

54. Kozak EA, Brath LK. Do “screening” coagulation tests predict bleeding in patients undergoing fiberoptic bronchoscopy with biopsy? Chest. 1994;106:703-5
274 patients undergoing 305 fiberoptic bronchoscopy and biopsy procedures at a tertiary care institution
Prolonged hemostatic studies prior to the procedure were noted in 10% (n=28) of patients
35 patients bled, but 32 of these had normal pre- procedure hemostatic values
3 patients had severe bleeding and each of them had normal pre-procedure test results

55. Diette GB, Wiener CM, White P Jr
Diette GB, Wiener CM, White P Jr. The higher risk of bleeding in lung transplant recipients from bronchoscopy is independent of traditional bleeding risks: results of a prospective cohort study. Chest. 1999;115:
720 bronchoscopies performed over a one-year period at Johns Hopkins and used multivariate analysis to determine factors that correlated with bleeding complications
They found that bleeding did not correlate with coagulation parameters or platelet count

56. Excess bleeding - > 100 mL in > 50% of animals
Brickey DA, Lawlor DP. Transbronchial biopsy in the presence of profound elevation of the international normalized ratio. Chest 1999;115:
Transbronchial biopsies on 18 pigs who were treated with escalating doses of warfarin
Goal = to determine the INR level at which excess bleeding would occur following the procedure
Excess bleeding - > 100 mL in > 50% of animals
They had planned to apply different post- procedure therapies to staunch the bleeding
But…the warfarin treated animals never developed bleeding despite having INR levels >10
11 of 18 pigs had INR>7 at the time of the biopsy

57. 1217 patients - 285 were taking aspirin at the time of the procedure
Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest. 2002;122:1461-4
Effect of aspirin on the extent of bleeding at the time of bronchoscopy and transbronchial lung biopsy
1217 patients were taking aspirin at the time of the procedure
57 patients (4.7 %) had bleeding complications
Incidence of minor (1.8 vs 2.9%), moderate (1.1 vs 1.4%), and severe (0.8 vs 0.9%) bleeding was not statistically different among those taking aspirin and those who did not

58. Plavix is not Aspirin Ernst A, Eberhardt R, Wahidi M, et al
Plavix is not Aspirin Ernst A, Eberhardt R, Wahidi M, et al. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest. 2006;129:734-7
Prospective observational study
Patients undergoing transbronchial biopsy were not required to cease aspirin or clopidogrel before the procedure
The post-procedure severe bleeding rate was 28% for clopidogrel alone, 50% for combined use, and 2 of 574 (0.3%) of the control group (of whom 111 were on aspirin alone)

59. Bottom line
There is no strong evidence to support component therapy to protect patients from bleeding complications
Although, I feel sympathy for a respirologists nervousness for doing this procedure given the consequences
Don’t worry about ASA use
For transbronchial biopsy, platelet count >25-30 and INR <2 is reasonable compromise
Stop oral P2Y12-R antagonists

60. Renal biopsy
A 64 year old woman with acute onset of combined hepatic and renal dysfunction is booked for a renal biopsy
INR is 1.9
Platelet count is 142
Creatinine in 345
Hemoglobin is 103
Would you give her FFP?

61. 471 consecutive percutaneous renal biopsies
Manno C, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int. 2004;66:1570-7
471 consecutive percutaneous renal biopsies
Hematoma seen in 33.3% of patients (clinically silent in 90%)
4 major hematomas observed (0.8%)
When patients with and without bleeding complications were compared - no difference in the baseline platelet count or PT
The PTT was higher in the patients with these clinically silent hematomas, 102.7% compared to 100.1% (p=0.01), making this finding of questionable importance

62. 162 patients undergoing percutaneous renal biopsy
Waldo B, et al. The value of post-biopsy ultrasound in predicting complications after percutaneous renal biopsy of native kidneys. Nephrol Dial Transplant. 2009;24:
162 patients undergoing percutaneous renal biopsy
No difference in the PT, aPTT, serum creatinine or hemoglobin at the time of biopsy between patients with (n=26) and without a complication (n=136)

63. Bottom line
No published evidence to support correction of the INR/PTT or platelet count before this procedure

64. Lumbar puncture
19 year old female with ALL planned for a diagnostic and therapeutic LP (IT MTX)
Her platelet count is 38
Her INR is 1.3, PTT 34
Would you transfuse anything prior to the procedure?

65. Complications are really rare
Risk of spinal hematoma following epidural anesthesia - 1 in 280,000 procedures
Stafford-Smith M. Can J of Anaesthesiology. 1996; 43:R
The risk of spinal hematoma following lumbar puncture is thought to be lower than that for epidural anesthesia, although reliable estimates are unavailable
van Veen JJ, et al. Brit J of Haem 2010;148:15-25

66. Lumbar punctures in 226 children with leukemia
Van Venn JJ, Vora AJ, and Welsh JC. Lumbar puncture in thrombocytopenic patients. Brit J of Haematology 2004; 127: 233-4
Lumbar punctures in 226 children with leukemia
Baseline platelet counts were:
< 10 in 19 patients
10-20 in 49
20-50 in 89 patients
No bleeding complications in any patient

67. Ruell J et al. Platelet count has no influence on traumatic and bloody lumbar puncture in children undergoing intrathecal chemotherapy. Br J Haematol. 2007;136:347-8
Ruell et al reported no bleeding complications after 738 lumbar punctures in 54 children with leukemia with platelet counts between 30 and >90
In addition, there was no correlation between the platelet count and the incidence of ‘bloody taps’

68. 5,000 lumbar punctures in 958 consecutive children with leukemia
Howard SC, et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA. 2000;284: Howard SC, et al. Risk factors for traumatic and bloody lumbar puncture in children with acute lymphoblastic leukemia. JAMA. 2002;288:
5,000 lumbar punctures in 958 consecutive children with leukemia
170 done in patients with counts between 10-20
742 done in patients with counts between 20–50
858 done in patients with counts between 50–100
Platelet transfusions were not given prior to the LP
No patient developed spinal hematoma or a clinical bleeding complication

69. Bottom line
There is no evidence that patients with platelet counts between have a higher risk of complications than patients with higher platelet counts

70. What about regional anesthesia?
No complications in 170 patients undergoing regional anesthesia with counts between
Frenk V, Camann W and Shankar KB. Regional anesthesia in parturients with low platelet counts. Can JAnaesth. 2005;52,114.
No complications in 65 patients of 10,369 births undergoing regional anesthesia with counts <150 (only 9 patients had counts<100)
Bernstein K, Baer A, Pollack M, et al. Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia. J Perin Med. 2008;36,120–3.
No complications in 25 patients of 10,203 births undergoing regional anesthesia with platelet counts <100
Deruddre S, Peyrouset O and Benhamou D. [Anesthetic management of 52 deliveries in parturients with idiopathic thrombocytopenic purpura]. J Gynecol Obstet Biol Reprod (Paris). 2007;36,384–8.

71. van Veen JJ, et al. The risk of spinal haematoma following neuraxial anesthesia or lumbar puncture in thrombocytopenic individuals. Brit J of Haematol. 2010;148:15-25
In a superb review of the risks of spinal hematoma following regional anesthesia, the authors conclude that there is sufficient literature to conclude that a platelet count >80 is sufficient for an epidural or spinal anesthesia
They also state that it is likely that it is safe to perform this procedure at lower platelet counts but at this time there is insufficient literature to recommend a lower level

72. Summary
Bleeding complications at the time of a procedure are exceptionally rare
Mildly abnormal test results do not imply clinically abnormal clotting (coagulopathy)
Platelet reserve is likely MORE important than deficits in coagulation factors
It is time to switch to a ‘therapeutic’ mode (not ‘prophylactic’) – only treat bleeding when it happens
If you are very conservative and nervous clinician
PLT 25 and INR 2