Can a patient with dengue syndrome and normal vital signs, but with thrombocytopenia (low platelet count), undergo completion curettage with spinal anesthesia?

Spinal Anesthesia in Dengue Syndrome with Normal Platelets

If the patient with dengue syndrome has truly normal platelet counts (>100,000/μL), stable vital signs, and no other coagulation abnormalities, spinal anesthesia can be safely administered for completion curettage. 1

Critical Assessment Required

Before proceeding with spinal anesthesia, you must verify the following parameters:

Platelet Count Thresholds

• Platelet count ≥70,000/μL is generally acceptable for spinal anesthesia in patients without other bleeding risk factors 1
• Platelet count >75,000/μL is considered low-risk when the count is stable and not decreasing 1
• For normal healthy women, platelet counts >100,000/μL carry no increased risk of spinal hematoma 1

Additional Coagulation Parameters to Check

You must rule out other dengue-related coagulopathy beyond just platelet count:

• Verify coagulation screen (PT/INR, aPTT) is normal - dengue can cause coagulation factor abnormalities even with normal platelet counts 1
• Confirm platelet function is expected to be normal - dengue can cause platelet dysfunction independent of count 1
• Ensure the platelet count is stable or rising, not rapidly falling - dengue can cause dynamic thrombocytopenia 1
• Rule out signs of severe dengue (plasma leakage, severe bleeding, organ impairment) that might indicate evolving coagulopathy 1

Decision Algorithm

If platelet count is >100,000/μL:

• Proceed with spinal anesthesia as normal risk 1
• No additional precautions beyond standard practice required 1

If platelet count is 70,000-100,000/μL:

• Obtain coagulation screen (PT, aPTT, fibrinogen) immediately before procedure 1
• If coagulation screen is normal and count is stable, spinal anesthesia is acceptable 1
• Consider this increased risk but still reasonable given risks of general anesthesia 1

If platelet count is 50,000-70,000/μL:

• This represents higher risk territory 1
• Requires multidisciplinary discussion with hematology 1
• May still be reasonable if coagulation screen normal, count stable, and patient has no bleeding history 1
• Spinal anesthesia may be safer than epidural at this threshold (single needle pass vs catheter) 2

If platelet count is <50,000/μL:

• Generally avoid neuraxial anesthesia 1
• Consider general anesthesia despite its risks 1

Important Dengue-Specific Considerations

Dengue causes thrombocytopenia through multiple mechanisms:

• Bone marrow suppression 1
• Increased platelet destruction 1
• Potential platelet dysfunction even with adequate counts 1

The platelet count in dengue can drop rapidly:

• If the patient is in the critical phase of dengue (days 3-7 of illness), recheck platelet count immediately before the procedure even if recent values were acceptable 1
• A count obtained >6 hours prior may not reflect current status in active dengue 1

Weighing Risks of General vs Spinal Anesthesia

The decision must balance spinal hematoma risk against general anesthesia complications:

Risks of general anesthesia in this patient:

• Airway difficulties and hypoxemia 1
• Aspiration risk if not adequately fasted 1
• Thromboembolic complications 1
• Overall serious morbidity rate of 6.5% when general anesthesia used to avoid neuraxial in thrombocytopenia 3

Risk of spinal hematoma:

• With platelets >70,000/μL and normal coagulation: estimated 0-0.6% 3
• No cases reported in large series with platelets >50,000/μL and stable counts 2, 3

Common Pitfalls to Avoid

• Do not rely solely on platelet count - dengue can cause qualitative platelet defects and coagulation factor abnormalities 1
• Do not use outdated platelet values - in active dengue, counts can fall precipitously; obtain fresh labs if >6 hours old 1
• Do not ignore bleeding history - any history of unusual bleeding with dengue suggests platelet dysfunction requiring higher thresholds 1
• Do not proceed if patient has signs of severe dengue (shock, severe bleeding, organ failure) regardless of platelet count 1