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Abstract
Introduction
Case Report
Discussion
Conclusion
References
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  Table of Contents 
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 48-51
 

Central neuraxial blockade in chronic immune thrombocytopenic purpura: Platelet count or function and the concept of rebalanced hemostasis


Department of Anaesthesiology, Saifee Hospital, Mumbai, Maharashtra, India

Date of Submission23-Oct-2016
Date of Acceptance15-Nov-2016
Date of Web Publication16-Dec-2016

Correspondence Address:
Tasneem Dhansura
Department of Anaesthesiology, Saifee Hospital, 15/17 Maharshi Karve Road, Opposite Charni Road Railway Station, Mumbai - 400 004, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0311.195961

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  Abstract 

Anesthetic management of patients having immune thrombocytopenic purpura (ITP) remains a challenge for the anesthesiologist. Surgeries such as knee arthroplasty are associated with significant bleeding. Neuraxial anesthesia is often preferred for knee arthroplasty. However, in patients with bleeding diathesis such as ITP, neuraxial anesthetic management remains controversial as there are no specific guidelines, and there is a risk of spinal hematoma. There are numerous case reports of safe regional anesthesia administered in parturients suffering from thrombocytopenia, but no explanation has been given. A new emerging concept of "rebalanced hemostasis" is now being used to explain the discrepancies observed in the laboratory reports versus the actual bleeding. In our case report, we have reviewed the literature and described the anesthetic management of a patient having chronic ITP and chronic obstructive pulmonary disease undergoing knee arthroplasty under neuraxial technique.


Keywords: Bleeding diathesis, central neuraxial blockade, chronic immune thrombocytopenic purpura, epidural hematoma, rebalanced hemostasis


How to cite this article:
Dhansura T, Shaikh N, Shaikh T, Madaoo M. Central neuraxial blockade in chronic immune thrombocytopenic purpura: Platelet count or function and the concept of rebalanced hemostasis. Indian Anaesth Forum 2016;17:48-51

How to cite this URL:
Dhansura T, Shaikh N, Shaikh T, Madaoo M. Central neuraxial blockade in chronic immune thrombocytopenic purpura: Platelet count or function and the concept of rebalanced hemostasis. Indian Anaesth Forum [serial online] 2016 [cited 2017 Oct 18];17:48-51. Available from: http://www.theiaforum.org/text.asp?2016/17/2/48/195961



  Introduction Top


Immune thrombocytopenic purpura (ITP) or idiopathic thrombocytopenic purpura is an acquired disorder leading to immune-mediated destruction of platelets and inhibition of platelet release from the megakaryocyte. Postinfection in children, ITP is acute and self-limited. In adults, it runs a chronic course. ITP is characterized by mucocutaneous bleeding and often a very low platelet count with normal peripheral blood cells and smear. Patients usually present either with ecchymoses and petechiae or with thrombocytopenia incidentally found on a routine examination. Mucocutaneous bleeding or heavy menstrual bleeding may be present.[1]

A large number of references and guidelines for neuraxial anesthesia exist for patients receiving antithrombotic or thrombolytic therapy.[2],[3] However, no published references or guidelines exist regarding the "minimum safe" platelet count for neuraxial anesthesia in patients suffering from bleeding diathesis. Neuraxial anesthetic techniques are not widely used in ITP for concerns of potential hemorrhagic and subsequent neurologic complications.[4],[5] An individual decision is made taking into account the risks and benefits.


  Case Report Top


A 72-year-old patient on treatment for chronic obstructive pulmonary disease (COPD) and chronic ITP was scheduled for bilateral total knee replacement. Complete blood count (CBC) revealed thrombocytopenia with a platelet count of 69,000/μl on Coulter counter (manual count of 84,000/μl). Thromboelastography (TEG) and coagulation profile were within normal range. Spirometry revealed severe airflow obstruction, GOLD Stage III. Other biochemical parameters were unremarkable. She was receiving prednisolone 40 mg orally once a day for more than 6 months and had also received intravenous gamma globulin (IVIgG) dosed at 1-2 g/kg total for 5 days without significant improvement in her platelet counts (<100,000/μl).

The anesthetic and postoperative analgesia plan was explained, and a valid consent with the American Society of Anesthesiologists Status III risk was obtained. Adequate packed red blood cells and 1 unit of single donor platelets were arranged. Spinal anesthesia was given using 25-gauge Quincke needle in L3-L4 space, the sitting position using 0.5% bupivacaine 3.5 cc and 60 μg of buprenorphine. Tranexamic acid 10 mg/kg IV over 30 min before tourniquet inflation and 3 h after first dose, ondansetron 0.1 mg/kg IV over 5 min were given. Dexmedetomidine 0.5-2 μg/kg/h was used. Left total knee replacement was completed uneventfully.

Hourly, postoperative assessment was continued in the recovery room and ward for the extent of motor block and return of function. Multimodal analgesia comprising paracetamol and patient-controlled analgesia infusion pump with low-dose IV fentanyl continuous infusion of 10 μg/h, a total of 260 μg over 24 h was required, lockout period being 30 min, and bolus dose of 4 μg per bolus was used considering the COPD status. Vitals, motor function, drain amount, and postoperative pain were recorded, and special attention was paid to bleeding from surgical site. CBC was repeated the next day. Contralateral knee replacement was done two days later and was managed similarly. The postoperative drainage from both the knees did not warrant any blood transfusion.


  Discussion Top


In the discussed case, neuraxial anesthesia was preferred because pulmonary functions were severely impaired. Neuraxial blockade in patients with COPD provides multiple benefits when compared with general anesthesia or systemic analgesia including better postoperative analgesia, decreased opioid-related side effects, unimpaired lung function, lower incidence of pneumonia, low incidence of unplanned postoperative intubation, or ventilator dependence, improved rehabilitation, and decreased morbidity and mortality.[6]

There is a potential risk of perioperative bleeding in patients with ITP. Several methods have been proposed to increase the preoperative platelet count to the "safe" level. The first-line therapy for ITP is the administration of corticosteroids (prednisolone 1 mg/kg). Rh0 (D) immune globulin at 50-75 mcg/kg and IVIgG at 1-2 g/kg total given over 1-5 days are also used. For emergent surgery, transfusion of single donor platelets or IVIgG can be used. The increase in platelet count can be expected to last for around 1 week following IVIgG infusion. Therefore, IVIgG is an important agent for preoperative management of a planned surgical procedure. However, IVIgG is not always effective, and a substantial increase in the platelet count is usually not achieved until 2-3 days following beginning of treatment. There are only two major indications for platelet transfusions in patients with ITP: (1) Temporary arrest of an acute life-threatening hemorrhage or (2) as preparation for surgery. It has been recommended transfusing platelet concentrations 1-2 h before performing surgery.[7]

Previous reports have suggested that neuraxial anesthesia was safely given with platelet counts between 50,000 and 80,000/μl. TEG was normal in our patient even though the platelet count was 69,000/μl [Figure 1]. A case series in parturients suggests that neuraxial techniques can be performed with a platelet count >56,000/μl and a normal TEG result.[8] As the minimum "safe" platelet count remains undefined, we administered neuraxial anesthesia weighing both pros and cons and use of TEG as a point of care testing.[9]
Figure 1: Normal thromboelastography in patient with platelet count of 69,000/μl

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It is known that in ITP, platelet count does not predict the risk of bleeding in individual patients. A focus on platelet count alone will lead to unnecessary platelet transfusions causing iatrogenic morbidity which may be worse than the disease itself. This phenomenon has been described as "medical nemesis." This goes on to prove there are other hemostatic mechanisms beyond the platelet count alone. A global assessment of hemostasis with TEG predicts bleeding in ITP. On examining the von Willebrand factor (vWF) in a group of patients with ITP, it was noticed that higher vWF was associated with better TEG values compared to those with lower vWF at similar platelet counts. In these patients, the clot formation time (CFT) and the alpha angle were larger. The CFT and alpha angle are sensitive to platelet number and function, fibrinogen levels, and polymerization.[10],[11]

Spinal hematoma after neuraxial techniques in modern anesthetic practice is rare. Still, it remains one of the most feared complications because of its potential for irreversible injury. However, it may be minimized with close attention to modifiable risk factors, traumatic needle insertion, and known coagulopathies.

Emphasis should be on assessing ITP patients postoperatively for the return of function after spinal anesthesia. If the patient develops a prolonged motor or sensory blockade, he/she should be assessed using computed tomography or magnetic resonance imaging.[12]

It should be noted that the source articles in our study are limited to case reports and case series with relatively few total subjects. It must be recognized that the absence of evidence does not imply evidence of absence. A high degree suspicion should be instituted.


  Conclusion Top


Regional anesthesia for arthroplasty in patients with ITP is not widely reported. Neuraxial anesthesia should be administered in ITP patients only after weighing individual risks and benefits as guidelines about "minimum safe" platelet counts are lacking. TEG as a point of care test should be used in assessing the platelet function and planning the anesthetic management. Thus, a global assessment of platelet function rather than platelet count alone is a better indicator of risk of bleeding in ITP. Postoperative assessment is as important as preoperative and intraoperative anesthetic management in these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Konkle B. Disorders of platelets and vessel wall. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscatzo J, editors. Harrison′s Principles of Internal Medicine. 19 th ed. New York: McGraw Hill Education; 2015. p. 728-9.  Back to cited text no. 1
    
2.
Englbrecht JS, Pogatzki-Zahn EM, Zahn P. Spinal and epidural anesthesia in patients with hemorrhagic diathesis: Decisions on the brink of minimum evidence? Anaesthesist 2011;60:1126-34.  Back to cited text no. 2
    
3.
Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015;40:182-212.  Back to cited text no. 3
    
4.
van Veen JJ, Nokes TJ, Makris M. The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. Br J Haematol 2010;148:15-25.  Back to cited text no. 4
    
5.
Yoo HS, Park SW, Han JH, Chung JY, Yi JW, Kang JM, et al. Paraplegia caused by an epidural hematoma in a patient with unrecognized chronic idiopathic thrombocytopenic purpura following an epidural steroid injection. Spine (Phila Pa 1976) 2009;34:E376-9.  Back to cited text no. 5
    
6.
Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg 2009;109:648-60.  Back to cited text no. 6
    
7.
Toyomasu Y, Shimabukuro R, Moriyama H, Eguchi D, Ishikawa K, Kishihara F, et al. Successful perioperative management of a patient with idiopathic thrombocytopenic purpura undergoing emergent appendectomy: Report of a case. Int J Surg Case Rep 2013;4:898-900.  Back to cited text no. 7
    
8.
Huang J, McKenna N, Babins N. Utility of thromboelastography during neuraxial blockade in the parturient with thrombocytopenia. AANA J 2014;82:127-30.  Back to cited text no. 8
    
9.
Thiruvenkatarajan V, Pruett A, Adhikary SD. Coagulation testing in the perioperative period. Indian J Anaesth 2014;58:565-72.  Back to cited text no. 9
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10.
Kim WH, Park JB, Jung CW, Kim GS. Rebalanced hemostasis in patients with idiopathic thrombocytopenic purpura. Platelets 2015;26:38-42.  Back to cited text no. 10
    
11.
Quinn CT. Lessons from the liver: Rebalanced hemostasis in immune thrombocytopenia. Hematologist 2014;11:12.  Back to cited text no. 11
    
12.
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;85:385-8.  Back to cited text no. 12
    


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