From the Guidelines
Surgery can be safely performed in patients with thrombocytopenia with a platelet count of 50 × 10^9 cells/L or greater, without the need for prophylactic platelet transfusion, as there is no evidence of increased perioperative bleeding risk in these patients. The decision to perform surgery in patients with thrombocytopenia should be based on the individual patient's risk factors and the type of surgery being performed 1. Some key points to consider when making this decision include:
- The platelet count: as mentioned, a count of 50 × 10^9 cells/L or greater is generally considered safe for major nonneuraxial surgery 1.
- The type of surgery: cardiac surgery may require a more cautious approach, with consideration of platelet transfusion in patients with perioperative bleeding and thrombocytopenia 1.
- The presence of coagulopathy: patients with coagulopathy may require more aggressive management, including platelet transfusion 1. It is also important to note that platelet transfusion has been identified as an independent predictor of adverse outcomes, including mortality, in some studies 1. Therefore, platelet transfusion should be withheld in nonbleeding surgical patients when the platelet count is greater than 50 × 10^9 cells/L and there is no evidence of coagulopathy. In contrast, platelet transfusion should be considered in cardiac surgical patients with perioperative bleeding and thrombocytopenia and/or suspected qualitative platelet abnormalities 1. Ultimately, the decision to perform surgery in patients with thrombocytopenia should be made on a case-by-case basis, taking into account the individual patient's risk factors and the type of surgery being performed.
From the Research
Surgery with Thrombocytopenia
- Thrombocytopenia is a common perioperative clinical problem, and its contribution to bleeding risk is difficult to predict 2.
- The benefits and risks of preoperative platelet transfusions should be assessed on a patient-by-patient basis, and alternatives to platelet transfusion should be considered 2.
- For non-emergent surgeries or in postoperative thrombocytopenic patients, haematology consultation should be considered to guide diagnostics and management 2.
Platelet Count Thresholds
- Tunneled or untunneled central venous catheters are low-risk procedures and can be safely performed without any intervention when the platelet count is 20 × 10^9/L or above 3.
- 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 × 10^9/L 3.
Management of Thrombocytopenia
- Patients with a platelet count greater than 50 × 10^3 per μL are generally asymptomatic, while those with platelet counts between 20 and 50 × 10^3 per μL may have mild skin manifestations 4.
- Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 10^3 per μL, in addition to treatment (when possible) of underlying causative conditions 4.
- Romiplostim and eltrombopag are effective second-line treatments for immune thrombocytopenia, with romiplostim appearing to have slightly fewer adverse effects and higher costs 5.