Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942009000200002
Brazilian Journal of Anesthesiology
Scientific Article

Anestesia regional e trombocitopenia não pré-eclâmptica; hora de repensar o nível seguro de plaquetas

Regional anesthesia and non-preeclamptic thrombocytopenia: time to re-think the safe platelet count

Motoshi Tanaka; Mrinalini Balki; Anne McLeod; Jose C. A. Carvalho

http://dx.doi.org/10.1590/S0034-70942009000200002 Braz J Anesthesiol, vol.59, n2, p.142-153, 2009
PDF Português
PDF English
Downloads: 9
Views: 2690

Resumo

JUSTIFICATIVA E OBJETIVOS: Apesar de a anestesia regional ser amplamente utilizada no controle da dor em obstetrícia, seu uso pode não ser apropriado nas pacientes com trombocitopenia por causa do risco de hematoma no neuroeixo. Não existem fortes evidências sugerindo número mínimo de plaquetas necessário para garantir a segurança na realização da anestesia regional. O objetivo deste estudo foi rever a segurança da anestesia regional em pacientes com trombocitopenia não pré-eclâmptica na instituição durante período de cinco anos. MÉTODO: Foi realizada revisão retrospectiva dos prontuários médicos de todas as pacientes obstétricas não pré-eclâmpticas cujo parto foi realizado na instituição entre abril de 2001 e março de 2006 e que apresentaram contagem de plaquetas < 100 x 10(9).L-1 no dia da anestesia. A etiologia da trombocitopenia, o tipo de anestesia, tipo de parto e as principais complicações anestésicas foram registrados. RESULTADOS: Foram identificadas 75 pacientes, das quais 47 (62,2%) receberam anestesia regional. A etiologia da trombocitopenia incluiu púrpura trombocitopênica imune, em 49 pacientes; trombocitopenia gestacional, em 20 pacientes; e outras causas em seis pacientes. Anestesia regional foi utilizada em 91,9% das pacientes com nível de plaquetas entre 80 a 99 x 10(9).L-1 e em 48,1% das pacientes com nível de plaquetas entre 50 e 79 x 10(9).L-1. Em nenhuma das 11 pacientes que apresentavam plaquetas abaixo de 50 x 10(9).L-1 foi administrada anestesia regional. Não houve complicações neurológicas. CONCLUSÕES: Nos casos estudados, a anestesia regional foi administrada com segurança nas gestantes com nível de plaquetas entre 50 - 79 x 10(9).L-1. Neste estudo os resultados são semelhantes aos de outras séries relatadas na literatura. Sugere-se que nas pacientes sem eclâmpsia com um nível estável de plaquetas e sem história prévia ou sinais clínicos de sangramento, o limite inferior de 50 x 10(9).L-1 deve ser adotado.

Palavras-chave

DOENÇAS, Hematológica, EXAMES COMPLEMENTARES, TÉCNICAS ANESTÉSICAS

Abstract

BACKGROUND AND OBJECTIVES: Although regional anesthesia is widely used for pain control in obstetrics, it may not be appropriate for patients with thrombocytopenia due to the risk of neuraxial hematoma. There is no strong evidence to suggest the minimum platelet count that is necessary to ensure the safe practice of regional anesthesia. The purpose of this study was to review the safety of regional anesthesia in non-preeclamptic thrombocytopenic parturients at our institution over a 5-year period. METHODS: A retrospective chart review was performed in all the non-preeclamptic obstetric patients who delivered at our facility between April 2001 and March 2006, and had platelet counts < 100 × 10(9).L-1 on the day of anesthesia. The etiology of the thrombocytopenia, type of anesthesia, mode of delivery and major anesthetic complications were noted. RESULTS: Seventy-five patients were identified, 47 of whom (62.6%) had received regional anesthesia. The etiology of their thrombocytopenia was immune thrombocytopenic purpura in 49 patients, gestational thrombocytopenia in 20 and other causes in 6 patients. Regional anesthesia was administered in 91.9% of the patients with platelet counts of 80 to 99 × 10(9).L-1 and in 48.1% of the patients with platelet counts of 50 to 79 × 10(9).L-1. None of the 11 patients with platelet counts below 50 × 10(9).L-1 received regional anesthesia. There were no neurological complications. CONCLUSIONS: In our series, regional anesthesia was safely administered in pregnant patients with platelet counts between 50-79 × 10(9).L-1. Our results are in keeping with other series in the literature. We suggest that in non-preeclamptic patients with stable platelet counts and no history or clinical signs of bleeding, the lower limit of platelet count for regional anesthesia should be 50 × 10(9).L-1

Keywords

ANESTHETIC TECHNIQUES, COMPLEMENTARY EXAMS, DISEASES, Hematologic

Referencias

Boehlen F, Hohfeld P, Extermann P. Platelet count at term pregnancy: a reappraisal of the threshold. Obstet Gynecol. 2000;95:29-33.

Burrows RF, Kelton JG. Fetal thrombocytopenia and its relation to maternal thrombocytopenia. N Engl J Med. 1993;329:1463-1466.

Douglas MJ. The Use of Neuraxial Anesthesia in Parturients with Thrombocytopenia: What Is an Adequate Platelet Count?. Evidence-Based Obstetric Anesthesia. 2005:165-177.

Warkentin TE, Kelton JG. Management of Thrombocytopenia. Hemostasis and Thrombosis: Basic Principles and Clinical Practice. 1994:470.

Hawkins JL, Koonin LM, Palmer SK. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology. 1997;86:277-284.

Cousins MJ, Bromage PR. Epidural Neural Blockade. Neural Blockade in Clinical Anesthesia and Management of Pain. 1988:335-336.

Letsky EA. Haemostasis and epidural anaesthesia. Int J Obstet Anesth. 1991;1:51-54.

Douglas MJ. Platelets, the parturient and regional anesthesia. Int J Obstet Anesth. 2001;10:113-120.

Practice Bulletin No. 36: Obstetric analgesia and anesthesia. Obstet Gynecol. 2002;100:177-191.

Orlikowski CEP, Rocke DA, Murray WB. Thromboelastography changes in pre-eclampsia and eclampsia. Br J Anaesth. 1996;77:157-161.

Rasmus KT, Rottman RL, Kotelko DM. Unrecognized thrombocytopenia and regional anesthesia in parturients: A retrospective review. Obstet Gynecol. 1989;73:943-946.

Shaley O, Anteby E. Epidural anesthesia can be safely performed in gestational thrombocytopenia of > 50,000/mL. Blood. 1996;88(^ssuppl):62b.

Webert KE, Mittal R, Sigouin C. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood. 2003;102:4306-4311.

Frenk V, Camann W, Shankar KB. Regional anesthesia in parturients with low platelet counts. Can J Anaesth. 2005;52:114.

Practice Bulletin No. 33: Diagnosis and management of preeclampsia and eclampsia. Obstet Gynecol. 2002;99:159-167.

Practice Bulletin No. 29: Chronic hypertension in pregnancy. Obstet Gynecol. 2001;98:177-185.

Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79:1165-1177.

Ruppen W, Derry S, McQuay H. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia. Anesthesiology. 2006;105:394-399.

Loo CC, Dahlgren G, Irestedt L. Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth. 2000;9:99-124.

Beilin Y, Abramovitz S. The anticoagulated parturient. Int Anesthesiol Clin. 2007;45:71-81.

Ballin NC. Paraplegia following epidural analgesia. Anaesthesia. 1981;36:952-953.

Newman B. Postnatal paraparesis following epidural analgesia and forceps delivery. Anaesthesia. 1983;38:350-351.

Crawford JS. Some maternal complications of epidural analgesia for labour. Anaesthesia. 1985;40:1219-1225.

Roscoe MW, Barrington TW. Acute spinal subdural hematoma: A case report and review of literature. Spine. 1984;9:672-675.

Jaeger M, Rickels E, Schmidt A. Lumbar ependymoma presenting with paraplegia following attempted spinal anaesthesia. Br J Anaesth. 2002;88:438-440.

Esler MD, Durbridge J, Kirby S. Epidural haematoma after dural puncture in a parturient with neurofibromatosis. Br J Anaesth. 2001;87:932-934.

Lao TT, Halpern SH, MacDonald D. Spinal subdural haematoma in parturient after attempted epidural anaesthesia. Can J Anaesth. 1993;40:340-345.

Yuen TST, Kua JSW, Tan IKS. Spinal haematoma following epidural anaesthesia in a patient with eclampsia. Anaesthesia. 1999;54:350-354.

Yarnell RW, D'Alton ME. Epidural hematoma complicating cholestasis of pregnancy. Curr Opin Obstet Gynecol. 1996;8:239-242.

Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth. 1990;64:537-541.

Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology. 2004;101:950-959.

Rolbin SH, Abbott D, Musclow E. Epidural anesthesia in pregnant patients with low platelet counts. Obstet Gynecol. 1988;71:918-920.

Beilin Y, Zahn J, Comerford M. Safe epidural analgesia in thirty parturients with platelet counts between 69,000 and 98,000 mm-3. Anesth Analg. 1997;85:385-388.

Hew-Wing P, Rolbin SH, Hew E. Epidural anaesthesia and thrombocytopenia. Anaesthesia. 1989;44:775-777.

Moeller-Bertram T, Kuczkowski KM, Benumof JL. Uneventful epidural labor analgesia in a parturient with immune thrombocytopenic purpura and platelet count of 26,000/mm³ which was unknown preoperatively. J Clin Anesth. 2004;16:51-53.

Kelton JG, Hunter DJS, Neame PB. A platelet function defect in preeclampsia. Obstet Gynecol. 1985;65:107-109.

Sharma SK, Philip J, Whitten CW. Assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. Anesthesiology. 1999;90:385-390.

Davies JR, Fernando R, Hallworth SP. Hemostatic function in healthy pregnant and preeclamptic women: an assessment using the platelet function analyzer (PFA-100®) and thromboelastograph®. Anesth Analg. 2007;104:416-420.

Kam PCA, Thompson SA, Liew ACS. Thrombocytopenia in the parturient. Anaesthesia. 2004;59:255-264.

Lind SE. The bleeding time does not predict surgical bleeding. Blood. 1991;77:2547-2552.

O'Kelly SW, Lawes EG, Luntley JB. Bleeding time: Is it a useful tool?. Br J Anaesth. 1992;68:313-315.

Vincelot A, Nathan N, Collet D. Platelet function during pregnancy: an evaluation using the PFA-100 analyser. Br J Anaesth. 2001;87:890-893.

Wee L, Sinha P, Lewis M. Central nerve block and coagulation: a survey of obstetric anaesthetists. Int J Obstet Anesth. 2002;11:170-175.

Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and pregnancy. Brit J Haematol. 2003;120:574-596.

5dd686850e8825024ac8fca7 rba Articles
Links & Downloads
2352-2291 (Electrónico) 0104-0014 (Impreso)
Braz J Anesthesiol ©2024 Todos los derechos reservados.

Braz J Anesthesiol

Share this page
Page Sections