Perioperative Platelet Transfusion for Obstetrics, Liver Disease, and Others
There are many challenging situations in which the anesthesiologist will have to make decisions about platelet therapy with little data. These include obstetric hemorrhage, advanced liver disease, and disseminated intravascular coagulopathy. For obstetric hemorrhage, the American College of Obstetricians and Gynecologists (Washington, D.C.) advocates using 1:1:1: ratios of red cells, plasma, and platelets until resuscitation can be guided by a laboratory-driven algorithm. In advanced liver disease, thrombocytopenia may be a misleading indicator of the patient's true bleeding tendency, and evidence from small trials suggests that transfusion algorithms incorporating viscoelastic testing reduce blood use but not mortality. For patients with disseminated intravascular coagulopathy who require surgery, there are no specific recommendations or guidelines; the anesthesiologist should be aware that patients may require larger-than-expected doses of platelets because of ongoing consumption.
Platelet transfusion is the primary therapy for patients with thrombocytopenia or platelet dysfunction who require procedures or surgery. Specific platelet triggers and goals vary with the clinical circumstances, and there is no high-quality evidence to guide perioperative practice. Stored donor platelets as they are currently available may not be an optimal therapy, and yet there are not proven alternatives in most situations. Platelet therapy is best guided by predefined protocols incorporating laboratory testing. It is acceptable under most society guidelines for patients to undergo low-risk procedures such as central lines and airway management with platelet counts greater than or equal to 20 × 103 cells/μl, high-risk percutaneous procedures and major surgery with counts greater than or equal to 50 × 103 cells/μl, neuraxial anesthesia with counts greater than or equal to 75 to 100 × 103 cells/μl, and neurologic or ophthalmological surgery with counts greater than or equal to 100 × 103 cells/μl. Most patients, however, will tolerate these procedures at lower platelet counts without severe complications. High-quality clinical trials investigating platelet storage technologies, platelet function testing, perioperative transfusion strategies, and alternatives to platelets are urgently needed. The anesthesiologist must weigh limited evidence alongside patient, operator, and institutional factors as they decide when to transfuse.
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Anesthesiology. 2021;134(3):471-479. © 2021 American Society of Anesthesiologists | Lippincott Williams & Wilkins