Download PDF
Semin Thromb Hemost 2020; 46(03): 245-255
DOI: 10.1055/s-0040-1702918
Review Article

Thrombocytopenia in Surgery and Neuraxial Anesthesia

Authors

  • Lise J. Estcourt

    1   NHS Blood and Transplant, Oxford, United Kingdom
    2   Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
Further Information
   Permissions and Reprints
Preview

Abstract

This is a review of the evidence for the use of different platelet count thresholds prior to invasive procedures and surgery. This review will focus on three procedures that are common in patients with thrombocytopenia—central venous catheter insertion, liver biopsy, and lumbar punctures and epidural catheters—as well as highlighting the lack of evidence for more major surgery. Tunneled or untunneled central venous catheters are low-risk procedures and can be safely performed without any intervention when the platelet count is 20 × 109/L or above. Evidence for their safety is more limited below this threshold, but as bleeding is easily treated, interventions should focus on treating any bleeding that occurs rather than preventative strategies. The available evidence for neuraxial anesthesia is based on very low-quality evidence from observational studies. Based on this evidence, the risk of an epidural hematoma is less than 0.19% (upper limit of 95% confidence interval) for pregnant women undergoing an epidural anesthetic when the platelet count is between 70 and 99 × 109/L. No randomized trials have been performed in children, nor have any randomized trials been performed in major or emergency surgeries.

Keywords

thrombocytopenia - surgery - anesthesia - epidural - lumbar puncture


Publication History

Publication Date:
07 April 2020 (online)

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Semple JW, Italiano Jr JE, Freedman J. Platelets and the immune continuum. Nat Rev Immunol 2011; 11 (04) 264-274
    Search in Google Scholar
  • 2 British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of platelet transfusions. Br J Haematol 2003; 122 (01) 10-23
    Search in Google Scholar
  • 3 Gernsheimer T, James AH, Stasi R. How I treat thrombocytopenia in pregnancy. Blood 2013; 121 (01) 38-47
    Search in Google Scholar
  • 4 Weinzierl EP, Arber DA. The differential diagnosis and bone marrow evaluation of new-onset pancytopenia. Am J Clin Pathol 2013; 139 (01) 9-29
    Search in Google Scholar
  • 5 Levi M, Toh CH, Thachil J, Watson HG. British Committee for Standards in Haematology. Guidelines for the diagnosis and management of disseminated intravascular coagulation. Br J Haematol 2009; 145 (01) 24-33
    Search in Google Scholar
  • 6 Neunert C, Lim W, Crowther M, Cohen A, Solberg Jr L, Crowther MA. American Society of Hematology. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 2011; 117 (16) 4190-4207
    Search in Google Scholar
  • 7 Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood 2017; 130 (21) 2271-2277
    Search in Google Scholar
  • 8 Hui P, Cook DJ, Lim W, Fraser GA, Arnold DM. The frequency and clinical significance of thrombocytopenia complicating critical illness: a systematic review. Chest 2011; 139 (02) 271-278
    Search in Google Scholar
  • 9 Afdhal N, McHutchison J, Brown R. et al. Thrombocytopenia associated with chronic liver disease. J Hepatol 2008; 48 (06) 1000-1007
    Search in Google Scholar
  • 10 Burrows RF, Kelton JG. Thrombocytopenia at delivery: a prospective survey of 6715 deliveries. Am J Obstet Gynecol 1990; 162 (03) 731-734
    Search in Google Scholar
  • 11 Nisha S, Amita D, Uma S, Tripathi AK, Pushplata S. Prevalence and characterization of thrombocytopenia in pregnancy in Indian women. Indian J Hematol Blood Transfus 2012; 28 (02) 77-81
    Search in Google Scholar
  • 12 Sainio S, Kekomäki R, Riikonen S, Teramo K. Maternal thrombocytopenia at term: a population-based study. Acta Obstet Gynecol Scand 2000; 79 (09) 744-749
    Search in Google Scholar
  • 13 Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll DL. Intensive Care Study of Coagulopathy Investigators. Thrombocytopenia and platelet transfusion in UK critical care: a multicenter observational study. Transfusion 2013; 53 (05) 1050-1058
    Search in Google Scholar
  • 14 Pendry K, Davies T. An audit of the use and wastage in the North West of England and North Wales - where have all the platelets gone?. Blood and Transfusion Matters 2011; 34: 17-19
    Search in Google Scholar
  • 15 Jones A, Birchall J, Roberts P. et al. A survey of where and why platelets are used in hospitals in the South West region of England. Transfus Med 2013; 23 (Suppl. 02) PO34
    Search in Google Scholar
  • 16 NICE. Blood transfusion. NICE guideline [NG24]. Accessed June 12, 2019 at: https://www.nice.org.uk/guidance/ng24
  • 17 Kaufman RM, Djulbegovic B, Gernsheimer T. et al; AABB. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2015; 162 (03) 205-213
    Search in Google Scholar
  • 18 Estcourt LJ, Birchall J, Allard S. et al; British Committee for Standards in Haematology. Guidelines for the use of platelet transfusions. Br J Haematol 2017; 176 (03) 365-394
    Search in Google Scholar
  • 19 Foster PF, Moore LR, Sankary HN, Hart ME, Ashmann MK, Williams JW. Central venous catheterization in patients with coagulopathy. Arch Surg 1992; 127 (03) 273-275
    Search in Google Scholar
  • 20 Barrera R, Mina B, Huang Y, Groeger JS. Acute complications of central line placement in profoundly thrombocytopenic cancer patients. Cancer 1996; 78 (09) 2025-2030
    Search in Google Scholar
  • 21 Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of hemostasis. Chest 1996; 110 (01) 185-188
    Search in Google Scholar
  • 22 Ray Jr CE, Shenoy SS. Patients with thrombocytopenia: outcome of radiologic placement of central venous access devices. Radiology 1997; 204 (01) 97-99
    Search in Google Scholar
  • 23 Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy--a prospective audit. Intensive Care Med 1999; 25 (05) 481-485
    Search in Google Scholar
  • 24 Mumtaz H, Williams V, Hauer-Jensen M. et al. Central venous catheter placement in patients with disorders of hemostasis. Am J Surg 2000; 180 (06) 503-505 , discussion 506
    Search in Google Scholar
  • 25 Carr E, Jayabose S, Stringel G. et al. The safety of central line placement prior to treatment of pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2006; 47 (07) 886-888
    Search in Google Scholar
  • 26 Loh AH, Chui CH. Port-A-Cath insertions in acute leukemia: does thrombocytopenia affect morbidity?. J Pediatr Surg 2007; 42 (07) 1180-1184
    Search in Google Scholar
  • 27 Tomoyose T, Ohama M, Yamanoha A, Masuzaki H, Okudaira T, Tokumine J. Real-time ultrasound-guided central venous catheterization reduces the need for prophylactic platelet transfusion in thrombocytopenic patients with hematological malignancy. Transfus Apheresis Sci 2013; 49 (02) 367-369
    Search in Google Scholar
  • 28 Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of hemostasis. Eur J Radiol 2008; 65 (02) 253-256
    Search in Google Scholar
  • 29 Della Vigna P, Monfardini L, Bonomo G. et al. Coagulation disorders in patients with cancer: nontunneled central venous catheter placement with US guidance--a single-institution retrospective analysis. Radiology 2009; 253 (01) 249-252
    Search in Google Scholar
  • 30 Weigand K, Encke J, Meyer FJ. et al. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters. Med Klin (Munich) 2009; 104 (05) 331-335
    Search in Google Scholar
  • 31 Cavanna L, Civardi G, Vallisa D. et al. Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1,978 consecutive catheterizations. World J Surg Oncol 2010; 8: 91
    Search in Google Scholar
  • 32 Haas B, Chittams JL, Trerotola SO. Large-bore tunneled central venous catheter insertion in patients with coagulopathy. J Vasc Interv Radiol 2010; 21 (02) 212-217
    Search in Google Scholar
  • 33 Zeidler K, Arn K, Senn O, Schanz U, Stussi G. Optimal preprocedural platelet transfusion threshold for central venous catheter insertions in patients with thrombocytopenia. Transfusion 2011; 51 (11) 2269-2276
    Search in Google Scholar
  • 34 Napolitano M, Malato A, Raffaele F. et al. Ultrasonography-guided central venous catheterisation in haematological patients with severe thrombocytopenia. Blood Transfus 2013; 11 (04) 506-509
    Search in Google Scholar
  • 35 Duffy SM, Coyle TE. Platelet transfusions and bleeding complications associated with plasma exchange catheter placement in patients with presumed thrombotic thrombocytopenic purpura. J Clin Apher 2013; 28 (05) 356-358
    Search in Google Scholar
  • 36 van de Weerdt EK, Biemond BJ, Zeerleder SS, van Lienden KP, Binnekade JM, Vlaar APJ. Study collaborative. Prophylactic platelet transfusion prior to central venous catheter placement in patients with thrombocytopenia: study protocol for a randomised controlled trial. Trials 2018; 19 (01) 127
    Search in Google Scholar
  • 37 Rocha LL, Pessoa CMS, Neto AS. et al; POCKET Trial Investigators. Thromboelastometry versus standard coagulation tests versus restrictive protocol to guide blood transfusion prior to central venous catheterization in cirrhosis: study protocol for a randomized controlled trial. Trials 2017; 18 (01) 85
    Search in Google Scholar
  • 38 Potet J, Thome A, Curis E. et al. Peripherally inserted central catheter placement in cancer patients with profound thrombocytopaenia: a prospective analysis. Eur Radiol 2013; 23 (07) 2042-2048
    Search in Google Scholar
  • 39 British Society of Gastroenterologists. BSG guidelines on the use of liver biopsy in clinical practice. Accessed June 10, 2019 at: https://www.bsg.org.uk/resource/bsg-guidelines-on-the-use-of-liver-biopsy-in-clinical-practice.html
  • 40 Rockey DC, Caldwell SH, Goodman ZD, Nelson RC, Smith AD. American Association for the Study of Liver Diseases. Liver biopsy. Hepatology 2009; 49 (03) 1017-1044
    Search in Google Scholar
  • 41 Kitchin DR, Del Rio AM, Woods M, Ludeman L, Hinshaw JL. Percutaneous liver biopsy and revised coagulation guidelines: a 9-year experience. Abdom Radiol (NY) 2018; 43 (06) 1494-1501
    Search in Google Scholar
  • 42 Midia M, Odedra D, Shuster A, Midia R, Muir J. Predictors of bleeding complications following percutaneous image-guided liver biopsy: a scoping review. Diagn Interv Radiol 2019; 25 (01) 71-80
    Search in Google Scholar
  • 43 Seeff LB, Everson GT, Morgan TR. et al; HALT–C Trial Group. Complication rate of percutaneous liver biopsies among persons with advanced chronic liver disease in the HALT-C trial. Clin Gastroenterol Hepatol 2010; 8 (10) 877-883
    Search in Google Scholar
  • 44 Napolitano G, Iacobellis A, Merla A. et al. Bleeding after invasive procedures is rare and unpredicted by platelet counts in cirrhotic patients with thrombocytopenia. Eur J Intern Med 2017; 38: 79-82
    Search in Google Scholar
  • 45 Kalambokis G, Manousou P, Vibhakorn S. et al. Transjugular liver biopsy--indications, adequacy, quality of specimens, and complications--a systematic review. J Hepatol 2007; 47 (02) 284-294
    Search in Google Scholar
  • 46 Mammen T, Keshava SN, Eapen CE. et al. Transjugular liver biopsy: a retrospective analysis of 601 cases. J Vasc Interv Radiol 2008; 19 (03) 351-358
    Search in Google Scholar
  • 47 Wallace MJ, Narvios A, Lichtiger B. et al. Transjugular liver biopsy in patients with hematologic malignancy and severe thrombocytopenia. J Vasc Interv Radiol 2003; 14 (03) 323-327
    Search in Google Scholar
  • 48 Basu P, Nair T, Farhat S, Shah NJ, Krishnaswamy N. Single use of romiplostim thrombopoietin analogue in thrombocytopenia for liver biopsy in chronic liver disease-randomized clinical trial. J Gastroenterol Hepatol 2012; 27 (Suppl. 05) 207-208
    Search in Google Scholar
  • 49 Estcourt LJ, Malouf R, Hopewell S, Doree C, Van Veen J. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev 2018; 4 (04) CD011980
    Search in Google Scholar
  • 50 Lee LO, Bateman BT, Kheterpal S. et al; Multicenter Perioperative Outcomes Group Investigators. Risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturients: a report from the Multicenter Perioperative Outcomes Group. Anesthesiology 2017; 126 (06) 1053-1063
    Search in Google Scholar
  • 51 Levy N, Goren O, Cattan A, Weiniger CF, Matot I. Neuraxial block for delivery among women with low platelet counts: a retrospective analysis. Int J Obstet Anesth 2018; 35: 4-9
    Search in Google Scholar
  • 52 Mainwaring C, Natarajan A, Peckham C, Readett D, Singhal R, Vazzalwar R. et al. Untreated thrombocytopenia and lumbar puncture-related bleeding risk at diagnosis of childhood acute lymphoblastic leukemia (ALL). Presented at the Conference of the British Society for Haematology, April 27–30, 1998, Glasgow, Scotland
  • 53 Howard SC, Gajjar A, Ribeiro RC. et al. Safety of lumbar puncture for children with acute lymphoblastic leukemia and thrombocytopenia. JAMA 2000; 284 (17) 2222-2224
    Search in Google Scholar
  • 54 Howard SC, Gajjar AJ, Cheng C. et al. Risk factors for traumatic and bloody lumbar puncture in children with acute lymphoblastic leukemia. JAMA 2002; 288 (16) 2001-2007
    Search in Google Scholar
  • 55 Feusner J. Platelet transfusion “trigger” for lumbar puncture. Pediatr Blood Cancer 2004; 43 (07) 793
    Search in Google Scholar
  • 56 Veen JJ, Vora AJ, Welch JC. Lumbar puncture in thrombocytopenic children. Br J Haematol 2004; 127 (02) 233-234 , author reply 234–235
    Search in Google Scholar
  • 57 Ruell J, Karuvattil R, Wynn R, Will A. Platelet count has no influence on traumatic and bloody lumbar puncture in children undergoing intrathecal chemotherapy. Br J Haematol 2007; 136 (02) 347-348
    Search in Google Scholar
  • 58 Kitanovski L, Trampus-Bakija A, Benedik-Dolnicar M. Prophylactic platelet transfusions before lumbar puncture. Zdrav Vestn 2008; 77: 111-115
    Search in Google Scholar
  • 59 Foerster MV, Pedrosa FP, da Fonseca TC, Couceiro TC, Lima LC. Lumbar punctures in thrombocytopenic children with cancer. Paediatr Anaesth 2015; 25 (02) 206-210
    Search in Google Scholar
  • 60 Vigil-De Gracia P, Silva S, Montufar C, Carrol I, De Los Rios S. Anesthesia in pregnant women with HELLP syndrome. Int J Gynaecol Obstet 2001; 74 (01) 23-27
    Search in Google Scholar
  • 61 Vavricka SR, Walter RB, Irani S, Halter J, Schanz U. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003; 82 (09) 570-573
    Search in Google Scholar
  • 62 Frenk V, Camann W, Shankar KB. Regional anesthesia in parturients with low platelet counts. Can J Anaesth 2005; 52 (01) 114
    Search in Google Scholar
  • 63 Palit S, Palit G, Vercauteren M, Jacquemyn Y. Regional anaesthesia for primary caesarean section in patients with preterm HELLP syndrome: a review of 102 cases. Clin Exp Obstet Gynecol 2009; 36 (04) 230-234
    Search in Google Scholar
  • 64 Tanaka M, Balki M, McLeod A, Carvalho JC. Regional anesthesia and non-preeclamptic thrombocytopenia: time to re-think the safe platelet count. Rev Bras Anestesiol 2009; 59 (02) 142-153
    Search in Google Scholar
  • 65 Goodier CG, Lu JT, Hebbar L, Segal BS, Goetzl L. Neuraxial anesthesia in parturients with thrombocytopenia: a multisite retrospective cohort study. Anesth Analg 2015; 121 (04) 988-991
    Search in Google Scholar
  • 66 Bernstein J, Hua B, Kahana M, Shaparin N, Yu S, Davila-Velazquez J. Neuraxial anesthesia in parturients with low platelet counts. Anesth Analg 2016; 123 (01) 165-167
    Search in Google Scholar
  • 67 Eypasch E, Lefering R, Kum CK, Troidl H. Probability of adverse events that have not yet occurred: a statistical reminder. BMJ 1995; 311 (7005): 619-620
    Search in Google Scholar
  • 68 Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? Interpreting zero numerators. JAMA 1983; 249 (13) 1743-1745
    Search in Google Scholar
  • 69 Rolbin SH, Abbott D, Musclow E, Papsin F, Lie LM, Freedman J. Epidural anesthesia in pregnant patients with low platelet counts. Obstet Gynecol 1988; 71 (6 Pt 1): 918-920
    Search in Google Scholar
  • 70 Rasmus KT, Rottman RL, Kotelko DM, Wright WC, Stone JJ, Rosenblatt RM. Unrecognized thrombocytopenia and regional anesthesia in parturients: a retrospective review. Obstet Gynecol 1989; 73 (06) 943-946
    Search in Google Scholar
  • 71 Shalev O, Anteby E. Epidural anesthesia can be safely performed in gestational thrombocytopenia of > 50,000/mL. Blood 1996; 88 (Supp): 62b
    Search in Google Scholar
  • 72 Beilin Y, Zahn J, Comerford M. Safe epidural analgesia in thirty parturients with platelet counts between 69,000 and 98,000 mm(-3). Anesth Analg 1997; 85 (02) 385-388
    Search in Google Scholar
  • 73 Sharma SK, Philip J, Whitten CW, Padakandla UB, Landers DF. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. Anesthesiology 1999; 90 (02) 385-390
    Search in Google Scholar
  • 74 Webert KE, Mittal R, Sigouin C, Heddle NM, Kelton JG. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood 2003; 102 (13) 4306-4311
    Search in Google Scholar
  • 75 Beilin Y, Arnold I, Hossain S. Evaluation of the platelet function analyzer (PFA-100) vs. the thromboelastogram (TEG) in the parturient. Int J Obstet Anesth 2006; 15 (01) 7-12
    Search in Google Scholar
  • 76 New HV, Berryman J, Bolton-Maggs PHB. et al; British Committee for Standards in Haematology. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175 (05) 784-828
    Search in Google Scholar
  • 77 Estcourt LJ, Malouf R, Doree C, Trivella M, Hopewell S, Birchall J. Prophylactic platelet transfusions prior to surgery for people with a low platelet count. Cochrane Database Syst Rev 2018; 9 (09) CD012779
    Search in Google Scholar
  • 78 Stanca CM, Montazem AH, Lawal A, Zhang JX, Schiano TD. Intranasal desmopressin versus blood transfusion in cirrhotic patients with coagulopathy undergoing dental extraction: a randomized controlled trial. J Oral Maxillofac Surg 2010; 68 (01) 138-143
    Search in Google Scholar
  • 79 Veelo DP, Vlaar AP, Dongelmans DA. et al. Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy. Blood Transfus 2012; 10 (02) 213-220
    Search in Google Scholar
  • 80 De Pietri L, Bianchini M, Montalti R. et al. Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: a randomized, controlled trial. Hepatology 2016; 63 (02) 566-573
    Search in Google Scholar
  • 81 Fillmore WJ, Leavitt BD, Arce K. Dental extraction in the thrombocytopenic patient is safe and complications are easily managed. J Oral Maxillofac Surg 2013; 71 (10) 1647-1652
    Search in Google Scholar
  • 82 Perdigão JPV, de Almeida PC, Rocha TDS. et al. Postoperative bleeding after dental extraction in liver pretransplant patients. J Oral Maxillofac Surg 2012; 70 (03) e177-e184
    Search in Google Scholar
  • 83 Nuvvula S, Gaddam KR, Kamatham R. Efficacy of tranexamic acid mouthwash as an alternative for factor replacement in gingival bleeding during dental scaling in cases of hemophilia: a randomized clinical trial. Contemp Clin Dent 2014; 5 (01) 49-53
    Search in Google Scholar
  • 84 Lee AP, Boyle CA, Savidge GF, Fiske J. Effectiveness in controlling haemorrhage after dental scaling in people with haemophilia by using tranexamic acid mouthwash. Br Dent J 2005; 198 (01) 33-38 , discussion 26
    Search in Google Scholar
  • 85 Afdhal NH, Giannini EG, Tayyab G. et al; ELEVATE Study Group. Eltrombopag before procedures in patients with cirrhosis and thrombocytopenia. N Engl J Med 2012; 367 (08) 716-724
    Search in Google Scholar
  • 86 Miller JB, Figueroa EJ, Haug RM, Shah NL. Thrombocytopenia in chronic liver disease and the role of thrombopoietin agonists. Gastroenterol Hepatol (N Y) 2019; 15 (06) 326-332
    Search in Google Scholar
  • 87 Curley A, Stanworth SJ, Willoughby K. et al; PlaNeT2 MATISSE Collaborators. Randomized trial of platelet-transfusion thresholds in neonates. N Engl J Med 2019; 380 (03) 242-251
    Search in Google Scholar
  • 88 Lye DC, Archuleta S, Syed-Omar SF. et al. Prophylactic platelet transfusion plus supportive care versus supportive care alone in adults with dengue and thrombocytopenia: a multicentre, open-label, randomised, superiority trial. Lancet 2017; 389 (10079): 1611-1618
    Search in Google Scholar
  • 89 Baharoglu MI, Cordonnier C, Salman RA-S. et al; PATCH Investigators. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet 2016; 387 (10038): 2605-2613
    Search in Google Scholar