LETTER TO EDITOR
Year : 2013 | Volume
| Issue : 4 | Page : 480-481
Anesthesia for a patient with thrombocytosis
TV Bharath Kumar1, Poorna Madhusudan2
1 Department of Critical Care, Fortis Hospitals, Bangalore, Karanataka, India
2 Department of Anesthesia, Apollo Hospitals, Bangalore, Karanataka, India
T V Bharath Kumar
Number 1554, 16th Main, JP Nagar, 2nd Phase, Bangalore - 560 078, Karnataka
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||7-Nov-2013|
|How to cite this article:|
Bharath Kumar T V, Madhusudan P. Anesthesia for a patient with thrombocytosis. Saudi J Anaesth 2013;7:480-1
A 70-year patient, a known case of hypertension, presented with history of bilateral knee pain from the last 3 years. A detailed history, examination and workup diagnosed bilateral osteoarthritis.
The patient was electively scheduled for a staged bilateral knee arthroplasty. Pre-op investigations incidentally detected an abnormally elevated platelet count (11.4 lakhs) and anemia (Hb: 9.8). A repeat platelet count was sought. The platelet count was found to be again high (10.15 lakhs). The patient was asymptomatic and had not suffered from any thrombotic/bleeding episodes. All other parameters were within normal limits. A peripheral smear was obtained on the advice of the physician and the smear revealed moderate-severe anisopoikilocytosis and a microcytic hypochromic anemia with many ovalocytes/pencil cells and severe thrombocytosis. An ultrasonography of the abdomen was performed and it revealed mild splenomegaly with normal echogenicity. The physician recommended a bone marrow study and the marrow study was planned in the intra-op period during the Total Knee Arthroplasty.
The patient and attendants were explained the risk and also the fact that a bone marrow sample would be taken in the intra-op period. In view of the thrombocytosis and the possibility of bleeding, spinal/epidural anesthesia was avoided. The surgery was performed under GA with femoral-sciatic nerve block. The femoral-sciatic nerve block was given prior to induction using ultrasound and peripheral nerve stimulator guidance. After induction with propofol, fentanyl and atracurium, the anesthesia was maintained with oxygen/Nitrous oxide/sevoflurane/atracurium combination. The bone marrow sample was taken by the surgeon before proceeding for implantation and despatched to the laboratory. The intra-op period was uneventful. Post-operatively the patient was transferred to the Intensive Care Unit as per institutional protocol and monitored for 24 h and then shifted to the ward. The post-op course was stable.
On follow-up, the bone marrow biopsy revealed a hypercellular marrow with megakaryocytic hyperplasia. Megakaryocytes were increased in number (4-5/hpf) with clustering. A possibility of essential thrombocythemia was suggested based on the bone marrow findings.
Very few cases of patients with thrombocytosis presenting for surgery have been reported. The main concerns for us as anesthesiologists is the risk of thrombotic episodes (MI/pulmonary infarcts) and the risk of excess bleeding during the peri-op period. Choice of anesthesia depends on the pre-op platelet count and aggregation studies. Spinal/epidural is not contraindicated if these investigations are within normal limits. A detailed history of such episodes in the past must be sought and the risks involved must be clearly explained to the patient.
In our case, we were fortunate to not encounter any problems. Okada and colleagues have reported two cases of patients presenting with the same problem.  They used an antiplatelet agent gabexate mesilate in the peri-op period in these patients.
Kimura and colleagues have also reported anesthesia for two patients with essential thrombocythemia, which is myeloproliferative disorder.  In one case, the pre-op platelet count was normal after myelosuppression therapy and they used a combination of GA with epidural. In the second case, as the platelet count was deranged, they chose only GA.
Garcia and colleagues have reported the use of spinal anesthesia in a patient with essential thrombocythemia.  In their case, the patient's pre-op platelet counts and aggregation studies were normal and they proceeded with spinal anesthesia without any untoward events. Contrary to this, Meyer and colleagues reported a case of massive hemorrhage following multiple epidural punctures in a patient with thrombocythemia.  In their case, the patient suffered from chronic myeloid leukemia and had an abnormally elevated platelet count.
Thrombocytosis is not always essential thrombocythemia and this can only be diagnosed with a bone marrow study. In conclusion, the major concerns in the peri-op period in these patients remain the risk of thrombotic and bleeding episodes. Spinal/epidural anesthesia is not absolutely contraindicated if the pre-op tests are within normal limits. However caution is warranted.
| References|| |
|1.||Okada Y, Hino H, Nagahama H, Kinouchi H, Sakomoto M, Aoki T. Anesthesia in two patients with thrombocythemia. Masui. Japanese J Anaesthesiol 1997;46:1470-3. |
|2.||Kimura Y, Yamaguchi S, Nagao M, Mishio M, Okuda Y, Kitajima T. Anesthetic management of two patients with essential thrombocythemia. Masui, Japanese J Anaesthesiol 2001;50:545-7. |
|3.||Garcia FJ, Hernandez PJ, Garcia AC, Verdu TM. Subarachnoid block in a patient with essential thrombocythemia. Anesth Analg 2005;101:300. |
|4.||Meyer HH, Mlasowsky B, Ziemer G, Tryba M. Massive haemorrhage following multiple epidural punctures as a late complication in thrombocythemia. Anasth Intensivther Notfallmed 1985;20:287-8. |
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