Thrombocytopenia in Surgery and Neuraxial Anesthesia

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.

Acquired Platelet Dysfunction—Laboratory and Clinical Implications

“…In continuation, Estcourt provides a comprehensive review of the handling of thrombocytopenia in surgery and neuroaxial anesthesia. 2 Evidence is presented for the use of different platelet count thresholds prior to invasive procedures and surgery, taking into account the difficult balance of the benefit–risk ratio for the use of platelet transfusions. Beyond minor surgery, the review focuses on four procedures that are common in patients with thrombocytopenia: central venous catheter insertion, liver biopsy, lumbar punctures, and insertion of epidural catheters.…”