How to manage a pediatric patient with leukocytosis scheduled for elective surgery?

Management of Pediatric Patient with Leukocytosis (TLC 22,000) for Elective Surgery

Elective surgery should be postponed until the cause of leukocytosis is investigated and addressed, as proceeding with surgery could increase the risk of infectious complications and poor outcomes. 1

Assessment of Leukocytosis

• A white blood cell count of 22,000 (leukocytosis) requires evaluation before proceeding with elective surgery, as it may indicate underlying infection, inflammation, or other pathological processes 2
• Differentiate between pathological leukocytosis and physiological leukocytosis, as some elevation in WBC count can be a normal response to stress, medications, or other non-infectious causes 3
• Routine laboratory testing including complete blood count with differential, reticulocyte count, renal function tests, liver function tests, and bilirubin should be performed to establish baseline values and identify potential causes 4

Pre-operative Management

• Investigate the underlying cause of leukocytosis through:

  • Detailed history focusing on recent infections, medications, underlying conditions 4
  • Physical examination with attention to potential sources of infection 4
  • Additional investigations as indicated (blood cultures, imaging studies) 4

• Consider delaying elective surgery as in-hospital delay has been associated with:

  • Increased risk of postoperative infectious complications 1
  • Higher mortality rates 1
  • Increased hospital costs 1

Special Considerations for Specific Conditions

If Leukocytosis is Due to Hematologic Disorder:

• For patients with leukocytosis due to conditions like chronic myeloid leukemia:
  • Start intravenous hyperhydration (2.5-3 liters/m²/day) if WBC count >100 × 10⁹/L or signs of leukostasis 4
  • Consider cytoreductive therapy such as hydroxyurea (25-50 mg/kg/day) to reduce WBC count before elective surgery 4

If Leukocytosis is Due to Sickle Cell Disease:

• For patients with sickle cell disease:
  • Multidisciplinary collaboration between surgeon, anesthetist, and pediatric hematologist is essential 4
  • Preoperative transfusion may be required depending on the type of procedure and individual patient characteristics 4
  • Elective surgery should be postponed if there is an active infection or SCD acute event 4

Decision Algorithm for Proceeding with Surgery

1. If leukocytosis is resolving and no evidence of active infection:

   • Consider proceeding with surgery when WBC count is trending downward and approaching normal range 1

2. If leukocytosis persists but no evidence of infection after thorough workup:

   • Consider proceeding with surgery with appropriate antibiotic prophylaxis and close monitoring 4

3. If evidence of active infection:

   • Postpone elective surgery until infection is adequately treated 4
   • Elective surgery in the setting of active infection increases risk of surgical site infections and other complications 1

Perioperative Management if Surgery Proceeds

• Ensure appropriate antibiotic prophylaxis based on procedure type and patient factors 4
• Maintain adequate hydration throughout the perioperative period 4
• Monitor for signs of infection or inflammatory response 4
• Consider restrictive red blood cell transfusion strategy (hemoglobin threshold of 7-8 g/dL) unless specific indications for higher threshold exist 4
• For pediatric patients, blood components should be prescribed by volume rather than units:
  • RBCs: 10 ml/kg (expected to increase Hb by approximately 20 g/L)
  • Platelets: 10-20 ml/kg
  • Fresh frozen plasma: 10-15 ml/kg 4

Common Pitfalls to Avoid

• Proceeding with elective surgery without investigating the cause of leukocytosis, which may lead to increased postoperative complications 1
• Assuming leukocytosis is always indicative of infection, as it may be a normal physiologic response to surgery or other stressors 3
• Delaying surgery for mild leukocytosis that has been determined to be non-infectious in origin 3
• Failing to involve appropriate specialists (hematology, infectious disease) in the management of patients with significant leukocytosis 4