Evidence review: periprocedural use of blood products

Thrombocytopenia as an Independent Prognostic Indicator Following Extradural Spinal Tumor Resection

BACKGROUND

Few studies have examined the prognosis for patients with baseline thrombocytopenia undergoing extradural spine tumor resection.

OBJECTIVE

To evaluate mortality, readmission, and other 30-day outcomes in patients with varying degrees of preoperative thrombocytopenia undergoing osseous extradural tumor excision.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2011-2019. Patients were categorized according to baseline preoperative platelet count, in 25,000/μL increments: 125,000-149,000/μL, 100,000-125,000/μL, 75,000-100,000/μL, and < 75,000/μL. These were compared to a control group with platelet count >150,000/μL. Outcomes in each cohort were analyzed using multivariate logistic regression analysis.

RESULTS

The database search revealed 3,574 patients undergoing extradural tumor resection; 2,171 (4.8%) of patients with platelets 125,000-149,000/μL, 114 (3.2%) with 100,000-125,000/μL, 75,000-100,000/μL in 43 (1.2%), and < 75,000/μL in 42 (1.2%). Platelet counts <100,000/μL was associated with perioperative blood transfusion, cardiac complications, and non-home discharge, and 30-day mortality. On subgroup analysis for mortality, an interaction was present between individuals with moderate/severe thrombocytopenia and cervical tumors.

CONCLUSION

In patients undergoing surgery for extradural spine tumor, degree of baseline thrombocytopenia-rather than presence alone-is an independent predictor of several adverse events. Wherever possible, optimization of preoperative platelet count to at least 100,000/μL may improve outcomes.

Periprocedural use of avatrombopag for neurosurgical interventions: a strategy to avoid platelet utilization

This is the first report of successful use of avatrombopag for a patient with chronic liver disease undergoing a neurosurgical procedure.

Acute Subdural Hematoma Complicating Heparin-induced Thrombocytopenia: A Case Report

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated drug reaction to heparin use that causes platelet aggregation, followed by thrombocytopenia. Despite the thrombocytopenia, the main complications of HIT are thromboembolic in nature rather than hemorrhagic, and in particular, intracranial hemorrhage is rare. Herein, we describe a case of atraumatic acute subdural hematoma secondary to HIT, which was treated by platelet transfusion and surgery. A 77-year-old woman was admitted to our hospital for the treatment of severe aortic valve stenosis. Unfractionated heparin was administered during the preoperative period and during the aortic valve replacement surgery. Three days after the cardiac surgery, the patient presented with coma consistent with an acute subdural hematoma in the posterior fossa and obstructive hydrocephalus. Laboratory examination revealed a marked decrease of the platelet count to 40000/µL, and subsequent serological assay confirmed the diagnosis of HIT. The patient was treated by transfusion of platelets and fresh frozen plasma, and surgical removal of the hematoma. We started the administration of argatroban for substitution of heparin 4 days after the craniotomy. On day 13 after the neurosurgery, the patient developed cerebral infarction due to left middle cerebral artery occlusion and persistent right hemiparesis. We presented a rare case of the patient who developed acute subdural hematoma complicating HIT. Emergency craniotomy was successfully performed after administering platelet transfusions. Our experience with the present case suggests that platelet transfusions may be effective for performing emergency surgery for intracranial hemorrhage, even in patients with HIT.

Quality of Evidence-Based Guidelines for Transfusion of Red Blood Cells and Plasma: A Systematic Review

Many transfusion guidelines are available, but little appraisal of their quality has been undertaken. The quality of guidelines may potentially influence adoption. Our aim was to determine the quality of evidence-based transfusion guidelines (EBG) for red cells and plasma, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, and assess duplication and consistency of recommendations. MEDLINE and EMBASE were systematically searched for EBG from 2005 to June 3, 2016. Citations were reviewed for inclusion in duplicate. A guideline was included if it had a specified clinical question, described a systematic search strategy, included critical appraisal of the literature and a description of how recommendations were developed. Four to six physicians used AGREE II to appraise each guideline. Median and scaled scores were calculated, with each item scored on a scale of one to seven, seven representing the highest score. Of 6174 citations, 30 guidelines met inclusion criteria. Twenty six guidelines had recommendations for red cells and 18 included recommendations for plasma use. The median score, the scaled score and the interquartile range of the scaled score were: scope and purpose: median score 5, scaled score 60%, IQR (49-74%); stakeholder involvement 4, 43%, (33-49%); rigor of development 4, 41%, (19-59%); clarity of presentation 5, 69%, (52-81%); applicability 1, 16%, (9-23%); editorial independence 3, 43%, (20-58%). Sixteen guidelines were evaluated to have a scaled domain score of 50% or less. Variations in recommendations were found for the use of hemoglobin triggers for red cell transfusion in patients with acute coronary syndromes and for plasma use for patients with bleeding. Our findings document, limited rigor in guideline development and duplication and inconsistencies in recommendations for the same topic. The process of developing guidelines for red cells and plasma transfusion can be enhanced to improve implementation.

Necessity of preoperative activated partial thromboplastin time test as a predictor for surgical hemorrhage in obstetric and gynecological patients in China

BACKGROUND

On an international scale, the necessity of preoperative coagulation screen remains controversial, yet in China, coagulation screen is still a routine test before surgery required by the Ministry of Health of China.

METHODS

A retrospective review of 26,807 patients >18y presenting with problems related to the areas of gynecology and obstetrics from March 2013 to July 2015 was performed, and the rate of major bleeding and the amount of blood lost during surgery were compared among groups of patients grouped according to the values of preoperative APTT, the departments the patients belonged to, or the measures for intervention.

RESULTS

Groups with increased APTT had higher rates of major bleeding (9.80% & 26.14% vs 2.77%, P<0.001) and more blood loss (862.9 and 1455.6ml vs 194.0ml, P<0.001). And the same conclusion could be induced in both the obstetric and gynecological patients when they were taken into account separately. For obstetric patients, once those with high bleeding risks, e.g., placental abruption, placental implantation, or preoperative massive hemorrhage were excluded, groups with increased APTT would no longer demonstrated the higher rate of major bleeding (0.91% & 2.38% vs 0%, P=0.409 & 0.833) and would even have a lower amount of blood loss (202.76 and 228.09ml vs 322.13ml, P=0.003 and 0.027). In increased APTT patients without bleeding or bleeding tendency, FFP intervention would not make a difference in the rate of major bleeding (7.69% vs 8.37%, P=0.203) and the amount of blood loss (271.35ml vs 306.63, P=0.865).

CONCLUSION

For Chinese patients from the Obstetrics and Gynecology Departments, APTT is a good screen test to predict surgical hemorrhage.

Risk of Procedural Hemorrhage

Patients who are critically ill and hospitalized often require invasive procedures as a part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of hemorrhage. Central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture constitute a majority of the procedures performed in patients who are hospitalized. In this article, the authors will discuss the risk factors for bleeding complications from each of these procedures and methods to minimize risk. Physicians often correct coagulopathy prior to procedures to decrease bleeding risk, but there is minimal evidence to support this practice.

Preprocedural Coagulation Studies in Pediatric Patients Undergoing Percutaneous Intervention for Appendiceal Abscesses

The literature reports poor correlation between coagulation screening and prediction of bleeding risk in children. Our aim is to determine whether there is a role for coagulation studies in children undergoing percutaneous intervention for appendiceal abscesses. A retrospective review of 1805 patients presenting with a diagnosis of appendicitis from September 2008 to September 2013 was performed. Patients presenting with appendiceal abscess who underwent percutaneous intervention were selected for further review (n = 131). A total of 76 patients (58%) had normal coagulation studies, whereas 55 (42%) had elevated values. An international normalized ratio ≥ 1.3 was found in 26 patients. Patients with normal coagulation values had an incidence of bleeding of 1.3 per cent. In the abnormal coagulation group, 8 patients received fresh frozen plasma before intervention, whereas 47 did not. There was one hematoma noted in each group with an incidence of bleeding of 3.6 per cent. The overall incidence of hematoma was 2.3 per cent with no significant difference in bleeding risk between the normal and abnormal coagulation groups. In conclusion, although many patients are found to have elevated coagulation studies, most do not have bleeding complications after intervention. There is poor correlation between coagulation screening and postprocedural outcomes evidenced by the low risk of bleeding.