Presentation on theme: "Irrational Exuberance: Component Therapy Before Bedside Procedures"— Presentation transcript:
1Irrational Exuberance: Component Therapy Before Bedside Procedures Jeannie Callum, BA, MD, FRCPC, CTBSSunnybrook Health Sciences CentreAssociate Professor, University of Toronto
2Outline 3 recent papers Bedside procedures and the evidence: Central venous cathetersLiver biopsyThoracentesis & ParacentesisBronchoscopy &Transbronchial biopsyRenal BiopsyEpidural/Lumbar puncture
3Mayo 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 2008Solid organ percutaneous biopsies5,832 Kidney biopsies3,636 Liver biopsies1,174 Lung biopsies384 Pancreas biopsies4,155 Other biospies
4Local 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 >50INR<1.6Primary endpoint was major bleeding within 3 months of the procedureMajor bleeding = RBC transfusion, interventional radiology procedure, operative procedureFollow-up at 3 months was available for 95% of the patients
5Incidence 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)
7Large-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 placementSingle center report from the University of Pennsylvania Medical CenterReviewed the outcomes of 3,170 tunneled central venous catheter placements in 2,514 unique patients
8All 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 guidancePatients excluded from the analysis if they had received FFP or platelets between their last set of laboratory values and the procedureObjectives:Primary-incidence of bleeding in first 24 hoursSecondary-incidence of infection and catheter failure
9They 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>1.5They 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
10Large-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 valuesThe lowest platelet count was 3 and the highest INR was 3.8Despite 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
11Large-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 productsThis translates into approximately 344 adult doses of platelets and 1304 units of FFP administered needlessly
1228 ‘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, TexasAka borderline laboratory abnormalities (defined as an INR>1.3)75% had subdural hematomasCompared 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)
13There 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 groupThere were 7deaths (50%) in the rFVIIa group and 4 deaths (29%) in the no-rFVIIa group (p =0.22)
14Recombinant factor VIIa for the correction of coagulopathy before emergency craniotomy in blunt trauma patients J Trauma 2010; 68:
15Prothrombin complex concentrate vs rVIIa for reversal of coumarin anticoagulation Dickneite G. Thrombosis Res 2006; Jul 12: Epub ahead of print
16Prothrombin complex concentrate vs rVIIa for reversal of coumarin anticoagulation Dickneite G. Thrombosis Res 2006; Jul 12: Epub ahead of print
17Exploratory study on the reversal of warfarin with rFVIIa in healthy subjects Blood Epub April12, 2010Bleeding Time (same results for blood loss)NBT preBT post warfBT post treatmentPlacebo2418.729.526.340 ug/kg1220.732.328.980 ug/kg18.631.927.7PTNPT prePT post warfPT post treatmentPlacebo2413.027.326.740 ug/kg1212.926.814.780 ug/kg13.330.415.0
19INR 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:
20Role 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 studiesRole 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.”
21BleedNo BleedRatePT elevated22411 in 121PT not elevated2315611 in 68All Patients2518021 in 72
22FFP given before a procedure will not correct an INR <2
23The relationship between the INR and coagulation factors 60 ml/kg FFP = 4 L FFP100 %zone of normalhemostasis50 %15 ml/kg FFP30 %zone of anticoagulationINR11.31.72.02.23.0
24Effect of FFP on patients with INRs between <1.8 Abdel-Wahab OI, et al. Transfusion 2006; 46:
25Stanworth et al. Is fresh frozen plasma clinically effective? A systematic review of randomized controlled trials. Br J Haematol. 2004;126:57 trials evaluatedLiver 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.
26Globally there is no evidence… What about for specific procedures?
27What is the evidence for specific procedures? Bedside procedures and the evidence:Central venous cathetersLiver biopsyThoracentesis & paracentesisBronchoscopy & transbronchial biopsyRenal BiopsyEpidural/Lumbar puncture
28Central venous catheters 57 year old woman with AML needs a Hickman line insertion to commence chemotherapy todayHer 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 AMPlatelet count is 38No active bleeding and no bleeding historyWhat would you request?
29What do we know?Bleeding complications relate to inadvertant puncture of the carotid or subclavian arteryDenys 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:
30What 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 complicationsSznajder JI, et al. Arch Intern Med. 1986;146:
31SunnybrookAll our lines are placed with ultrasound guidance by experienced interventional radiologists0.5% x 0.22 = 0.11% (1 in 909 major bleed rate)
32CVC 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 abnormalitiesNo attempts were made to correct laboratory abnormalities before the procedureMean 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
33CVC 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 catheters22 catheters were placed with platelet counts of , 30 catheters with counts of 20-50, and 11 with counts below 2013 percent of patients had a combination of thrombocytopenia and prolongation of the PT/PTTNone were given transfusions of platelets or FFP before the procedureNone had serious complications, intrathoracic bleeding, or an unexpected drop in hematocrit
34More evidence115 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 coagsNosari AM, et al. Leuk Lymph. 2008;49:
35More 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 surgery252 (49%) were anticoagulated with heparinAn observer who was unaware of the anticoagulation status of each patient recorded the presence of an insertion site hematomaOf the 22 hematomas that occurred13 were in anticoagulated patients9 were in non-anticoagulated personsThis difference was not significant
36More evidence Fisher NC, et al. Intensive Care Med. 1999;25:481-5. 658 CVC line insertionsMedian 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 presentPatients were not given any pre-procedure transfusion of FFP or platelets1patient, with near normal tests, developed a hemothorax after inadvertent puncture of the subclavian arteryThere were no other major hemorrhagic complications
37More 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 procedure3 had bleeding complicationsNone had platelet counts <50 or INR>1.5
38Bottom 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 25-30There is no INR above which patients appear to be at higher risk
39Liver biopsy45 year old with cryptogenic cirrhosis needs a diagnostic percutaneous liver biopsy (with ultrasound guidance)His INR is 2.2, PTT 48, and platelet count 48He has no bleeding historyWhat would you order before the procedure?
40Liver BiopsyThe perfect patient population to test NOT giving prophylactic transfusions:Patients often have abnormal laboratory tests of coagulationThey are often thrombocytopenicThey have multiple other derangements of hemostasisYou can’t compress the liver if it bleeds
41Piccinino 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
42Ewe 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 bleedingNo degree of abnormal lab tests warranted pre- procedure therapy at this institutionThere was no correlation of liver bleeding time and laboratory test resultsEven patients with INR>3 and platelets<50 did not bleed more than patients with ‘better’ test results
449000 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 periodPatients had pre-procedure INR’s up to 1.8 and platelet counts as low as 55Post-biopsy hemorrhage occurred in 32 patientsThe lab values did not differ between the 32 with substantial bleeding and the rest of the patients
45Makris 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 scansHalf 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 50Two patients bled post-procedure and both of these had normal pre-procedure coagulation values
46Bottom 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
47Thoracentesis & Paracentesis 67 year old EtOHic male is admitted through the ER with query spontaneous bacterial peritonitis resulting in sepsisINR 5Platelet count 23He needs a diagnostic peritoneal tapWhat would you give him prior to the procedure?
48Pache 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 rareA recent large series of 4729 patients observing severe hemorrhage in only 0.19% of patients1 in 525 patients
49None 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 componentsBleeding complications occurred in 0.2%No difference between normal PT/PTT compared with those with a prolonged PT/PTTNo differences between platelet counts above 100 compared with those with counts of or 25-50
50There 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 procedureAll procedures were performed without ultrasound guidance and without the transfusion of platelets or plasmaThe lowest platelet count was 19 (IQR 42-56) and the highest INR was 8.7 (IQR )There was no significant bleeding in any patient
51GuidelinesIn 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:
52Transbronchial biopsy 68 year old man on ASA for a bare metal stent placed 1 year ago is booked for bronchoscopy and transbronchial biopsyHe has a history of 2 TIAsHis platelet count is normalWould you stop his ASA?
53Bronchoscopy 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 proceduresComplications are higher with transbronchial biopsy, estimated in one large series at approximately 2% for all patientsCredle 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:
54Kozak EA, Brath LK. Do “screening” coagulation tests predict bleeding in patients undergoing fiberoptic bronchoscopy with biopsy? Chest. 1994;106:703-5274 patients undergoing 305 fiberoptic bronchoscopy and biopsy procedures at a tertiary care institutionProlonged hemostatic studies prior to the procedure were noted in 10% (n=28) of patients35 patients bled, but 32 of these had normal pre- procedure hemostatic values3 patients had severe bleeding and each of them had normal pre-procedure test results
55Diette 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 complicationsThey found that bleeding did not correlate with coagulation parameters or platelet count
56Excess 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 warfarinGoal = to determine the INR level at which excess bleeding would occur following the procedureExcess bleeding - > 100 mL in > 50% of animalsThey had planned to apply different post- procedure therapies to staunch the bleedingBut…the warfarin treated animals never developed bleeding despite having INR levels >1011 of 18 pigs had INR>7 at the time of the biopsy
571217 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;122:1461-4Effect of aspirin on the extent of bleeding at the time of bronchoscopy and transbronchial lung biopsy1217 patients were taking aspirin at the time of the procedure57 patients (4.7 %) had bleeding complicationsIncidence 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
58Plavix 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;129:734-7Prospective observational studyPatients undergoing transbronchial biopsy were not required to cease aspirin or clopidogrel before the procedureThe 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)
59Bottom lineThere is no strong evidence to support component therapy to protect patients from bleeding complicationsAlthough, I feel sympathy for a respirologists nervousness for doing this procedure given the consequencesDon’t worry about ASA useFor transbronchial biopsy, platelet count >25-30 and INR <2 is reasonable compromiseStop oral P2Y12-R antagonists
60Renal biopsyA 64 year old woman with acute onset of combined hepatic and renal dysfunction is booked for a renal biopsyINR is 1.9Platelet count is 142Creatinine in 345Hemoglobin is 103Would you give her FFP?
61471 consecutive percutaneous renal biopsies Manno C, et al. Predictors of bleeding complications in percutaneous ultrasound-guided renal biopsy. Kidney Int. 2004;66:1570-7471 consecutive percutaneous renal biopsiesHematoma 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 PTThe 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
62162 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 biopsyNo 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)
63Bottom lineNo published evidence to support correction of the INR/PTT or platelet count before this procedure
64Lumbar puncture19 year old female with ALL planned for a diagnostic and therapeutic LP (IT MTX)Her platelet count is 38Her INR is 1.3, PTT 34Would you transfuse anything prior to the procedure?
65Complications are really rare Risk of spinal hematoma following epidural anesthesia - 1 in 280,000 proceduresStafford-Smith M. Can J of Anaesthesiology. 1996; 43:RThe risk of spinal hematoma following lumbar puncture is thought to be lower than that for epidural anesthesia, although reliable estimates are unavailablevan Veen JJ, et al. Brit J of Haem 2010;148:15-25
66Lumbar 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: 233-4Lumbar punctures in 226 children with leukemiaBaseline platelet counts were:< 10 in 19 patients10-20 in 4920-50 in 89 patientsNo bleeding complications in any patient
67Ruell J et al. Platelet count has no influence on traumatic and bloody lumbar puncture in children undergoing intrathecal chemotherapy. Br J Haematol. 2007;136:347-8Ruell et al reported no bleeding complications after 738 lumbar punctures in 54 children with leukemia with platelet counts between 30 and >90In addition, there was no correlation between the platelet count and the incidence of ‘bloody taps’
685,000 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 leukemia170 done in patients with counts between 10-20742 done in patients with counts between 20–50858 done in patients with counts between 50–100Platelet transfusions were not given prior to the LPNo patient developed spinal hematoma or a clinical bleeding complication
69Bottom lineThere is no evidence that patients with platelet counts between have a higher risk of complications than patients with higher platelet counts
70What about regional anesthesia? No complications in 170 patients undergoing regional anesthesia with counts betweenFrenk 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 <100Deruddre 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.
71van Veen JJ, et al. The risk of spinal haematoma following neuraxial anesthesia or lumbar puncture in thrombocytopenic individuals. Brit J of Haematol. 2010;148:15-25In 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 anesthesiaThey 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
72SummaryBleeding complications at the time of a procedure are exceptionally rareMildly abnormal test results do not imply clinically abnormal clotting (coagulopathy)Platelet reserve is likely MORE important than deficits in coagulation factorsIt is time to switch to a ‘therapeutic’ mode (not ‘prophylactic’) – only treat bleeding when it happensIf you are very conservative and nervous clinicianPLT 25 and INR 2