Should a platelet transfusion be given 1 hour before appendectomy in a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) who stopped taking clopidogrel (Plavix) and aspirin 2 days prior to surgery?

From the Guidelines

A platelet transfusion is generally not recommended 1 hour before appendectomy in a patient with NSTEMI who stopped clopidogrel and aspirin 2 days prior to surgery. The short 2-day discontinuation period of these antiplatelet medications does present an increased bleeding risk, but prophylactic platelet transfusion is not the standard approach in this situation, as supported by the 2012 American College of Chest Physicians evidence-based clinical practice guidelines 1. Platelets should typically be reserved for patients with active bleeding or severe thrombocytopenia (platelet count <50,000/μL).

For this NSTEMI patient, the surgical team should instead proceed with careful hemostatic technique during the appendectomy and be prepared for potential increased bleeding. The anesthesia team should ensure adequate intravenous access and have blood products available if needed during the procedure. Postoperatively, close monitoring for bleeding complications is essential. The decision to resume antiplatelet therapy should be made as soon as hemostasis is assured, typically within 24-48 hours post-surgery, as these medications are important for preventing thrombotic complications in NSTEMI patients.

Some key considerations include:

• The risk of bleeding complications in patients who underwent surgery and were initially treated with aggressive antiplatelet treatment, as noted in the PURSUIT trial and the CURE study 1.
• The importance of minimizing perioperative bleeding, especially mediastinal bleeding that can cause pericardial tamponade, as discussed in the 2012 American College of Chest Physicians guidelines 1.
• The potential benefits of continuing ASA prior to CABG surgery, including reduced overall mortality without a concomitant increased risk for reoperation, as found in an 8,000-patient cohort study 1.

However, given the specific context of appendectomy rather than CABG, and the recent discontinuation of clopidogrel and aspirin, the focus should be on careful surgical technique and monitoring rather than prophylactic platelet transfusion, in line with the principles outlined in the provided evidence 1.

From the Research

Platelet Transfusion in Patients with NSTEMI Undergoing Appendectomy

• The decision to give a platelet transfusion 1 hour before appendectomy in a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) who stopped taking clopidogrel and aspirin 2 days prior to surgery is complex and depends on various factors.
• According to the study 2, the typically recommended threshold of 50,000/µL for prophylactic platelet transfusion is based only on expert opinion, and substantial observational data indicate that this threshold leads to many transfusions that are likely unnecessary and therefore represent risk with little or no additional benefit.
• Another study 3 suggests that the recommended indication for prophylactic transfusion is a platelet count of 10,000/microL, but this may not be directly applicable to patients undergoing surgery.
• The study 4 recommends specific triggers ranging from 30 x 10(9) to 100 x 10(9) platelets/L for prophylactic platelet transfusion in selected clinical conditions, with higher values when surgical procedures are required for the patient's treatment.
• However, there is no clear consensus on the optimal threshold for prophylactic platelet transfusion in patients undergoing invasive procedures or major surgery, as stated in the study 2.
• The study 5 reports a case where a patient with Glanzmann thrombasthenia underwent surgery with platelet transfusion and oral tranexamic acid, and no bleeding or thrombotic events were observed.
• The guidelines 6 from the Italian Society for Haemostasis and Thrombosis (SISET) aim to provide the best available evidence for the management of bleeding or its prophylaxis in patients with disorders of platelet count or function, but do not provide specific recommendations for patients with NSTEMI undergoing appendectomy.

Considerations for Platelet Transfusion

• The patient's platelet count and function should be carefully evaluated before making a decision about platelet transfusion.
• The risk of bleeding and the potential benefits of platelet transfusion should be weighed against the potential risks, as stated in the study 4.
• The use of anti-hemorrhagic drugs, such as tranexamic acid, may be considered in addition to or instead of platelet transfusion, as reported in the study 5.
• A multidisciplinary approach, involving hematologists, surgeons, and anesthesiologists, may be necessary to determine the best course of action for the patient.