Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia

Abstract

We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.

How I treat type 2B von Willebrand disease

“…Epidural and spinal anesthesia are both common. Generally, the risk of epidural hematoma in obstetrics is very low (1 in 168 000 or less), 48,49 but the risk of bleeding with neuraxial anesthesia in type 2B VWD is not known. Although National Heart, Lung, and Blood Institute VWD guidelines consider neuraxial anesthesia an option in VWD when VWF:RCo is .50, 29 there have been strong recommendations against neuraxial anesthesia in patients with type 2 (and specifically 2B) VWD because of a lack of evidence and because of safety concerns.…”

“…Safe platelet counts and transfusion thresholds before lumbar puncture or epidural in general have not been established, but a platelet threshold .50 3 10 3 /mm 3 is most commonly recommended. 48,51 Coordination with a multidisciplinary team on delivery of VWF-containing therapies, platelet transfusion, monitoring, and minimization of trauma is essential. We recommend that if neuraxial anesthesia will be performed, it be done within 1 hour of VWF replacement therapy.…”

Thrombocytopenia in Surgery and Neuraxial Anesthesia

“…49 There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure. 49 Of the observational studies that have recorded side effects after lumbar punctures, most of the studies have been conducted in children or pregnant women (►Table 3). However, very few spinal anesthetic procedures have been conducted in women with a platelet count of 50 Â 10 9 /L or below.…”

“…16,18 Epidural catheters are larger and also remain in place for prolonged periods, and therefore they are expected to lead to a greater risk of harm than a lumbar puncture (including spinal anesthetic). 49 If we use the same rule of three for estimating the upper limit of the 95% CI for spinal epidural hematoma based on data given in ►Table 3, the upper limit is 0.17% with a platelet count of < 50 Â 10 9 /L (N ¼ 1,716) and 0.78% with a platelet count of < 20 Â 10 9 /L (N ¼ 385). 68 The threshold of 50 Â 10 9 /L is consistent with guidelines from NICE (National Institute for Health and Care Excellence) and similar to the British Society for Haematology (BSH) guidelines, which use a threshold of 40 Â 10 9 /L.…”

Rethinking the need for a platelet transfusion threshold of 50 × 109/L for lumbar puncture in cancer patients

“…The recommendation comes from a number of expert panels, such as the American Association of Blood Banks and American Society of Clinical Oncology (ASCO), who by necessity based their decisions on low-grade evidence lacking any randomized control trials (RCTs). [3][4][5][6] However, some retrospective studies have challenged this practice, providing evidence that it is safe to perform an LP at much lower platelet thresholds. 7,8 Howard et al, 7 conducted the largest retrospective data review of pediatric patients undergoing LPs with platelet counts less than 50 × 10 9 /L.…”