From the Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
Obstetric Anesthesia Committee, World Federation of Societies of Anesthesiologists, London, United Kingdom.
Anesth Analg. 2023 May 1;136(5):992-998. doi: 10.1213/ANE.0000000000006217. Epub 2022 Oct 13.
In resource-limited environments, spinal anesthesia (SA) is preferred for cesarean delivery. In women at risk of spinal epidural hematoma, particularly those with hypertensive disorders of pregnancy, thrombocytopenia should be excluded before neuraxial blockade. In the context of emergency surgery for fetal distress, this investigation may be hampered by laboratory services being unavailable or off-site.
The Obstetric Airway Management Registry (ObAMR) is currently active across all anesthesia training institutions affiliated with the University of Cape Town. This multicenter observational study aimed to estimate the proportion of patients receiving general anesthesia (GA) for either confirmed or suspected thrombocytopenia, which was not excluded due to unavailability of laboratory results. To establish the number of GA uses that may have been avoided if platelet counts were available, we retrospectively searched for subsequent platelet counts in patients for whom thrombocytopenia was suspected. An algorithm was proposed, including a simple decision aid for estimating risk versus benefit of SA versus GA, to be followed in the setting of hypertensive disorders of pregnancy and thrombocytopenia.
Thrombocytopenia was the indication for GA in 100 of 591 patients (16.9%) captured in the registry. In total, 48 of 591 (8.1%) had confirmed thrombocytopenia, and 52 of 591 (8.8%) had suspected thrombocytopenia. Of these patients, 91 of 100 had a hypertensive disorder of pregnancy. In the confirmed thrombocytopenia group, the indication for GA was a platelet count <75 × 10 9 /L. In the suspected thrombocytopenia group, 46 of 52 (88.5%) platelet counts could be retrospectively traced. The median (interquartile range) platelet count was 178 × 10 9 /L (93 - 233 × 10 9 /L), and platelets exceeded 75 × 10 9 /L in 41 of 46 patients (89.1%). In the 5 of 46 patients with retrospectively confirmed thrombocytopenia, 2 had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, 2 had antepartum hemorrhage with preeclampsia, and 1 had isolated thrombocytopenia with preeclampsia.
In 17% of patients, the indication for GA was thrombocytopenia. Of these, 52 of 100, or nearly 9% of the total of 591, received GA because a platelet count was unavailable at the time of surgery. The importance of early laboratory assessment, when available, should be emphasized. Overall, 41 of 591 (6.9%) had a platelet count >75 × 10 9 /L and would not have needed GA if their platelet count had been known. After following the constructed algorithm and applying the decision aid to assess risk and benefit, there may be circumstances in which the clinician justifiably opts for SA when a platelet count is indicated but unavailable.
在资源有限的环境中，椎管内麻醉（SA）是剖宫产的首选。对于有脊髓硬膜外血肿风险的女性，特别是有妊娠高血压疾病的女性，在进行神经轴阻滞前应排除血小板减少症。在因胎儿窘迫而紧急进行外科手术的情况下，由于实验室服务不可用或不在现场，可能会妨碍进行这种检查。
产科气道管理登记处（ObAMR）目前在与开普敦大学相关的所有麻醉培训机构中活跃。这项多中心观察性研究旨在估计因实验室结果不可用而未排除确认或疑似血小板减少症的患者中接受全身麻醉（GA）的比例。为了确定如果可以获得血小板计数，可能避免的 GA 使用次数，我们回顾性地搜索了疑似血小板减少症患者的后续血小板计数。提出了一种算法，包括一个用于估计 SA 与 GA 风险与获益的简单决策辅助工具，以便在妊娠高血压疾病和血小板减少症的情况下使用。
在登记处中，有 591 名患者中有 100 名（16.9%）因血小板减少症而需要 GA。总的来说，有 48 名（8.1%）有确诊的血小板减少症，52 名（8.8%）有疑似血小板减少症。这些患者中有 91 名（81.2%）患有妊娠高血压疾病。在确诊的血小板减少症组中，GA 的指征是血小板计数<75×10^9/L。在疑似血小板减少症组中，可以追溯到 52 名（88.5%）患者的 46 名血小板计数。中位数（四分位距）血小板计数为 178×10^9/L（93-233×10^9/L），在 46 名患者中有 41 名（89.1%）血小板计数超过 75×10^9/L。在 46 名疑似血小板减少症患者中，有 5 名（10.9%）的血小板计数得到了回顾性确认，其中 2 名患有溶血性肝酶升高和低血小板（HELLP）综合征，2 名患有产前出血合并子痫前期，1 名患有孤立性血小板减少症合并子痫前期。
在 17%的患者中，GA 的指征是血小板减少症。其中，有 52 名（88.2%），即 100 名患者中的 52 名，或总数 591 名患者中的近 9%，因手术时血小板计数不可用而接受了 GA。当有条件时，应强调早期实验室评估的重要性。总的来说，如果已知血小板计数，有 41 名（6.9%）患者的血小板计数>75×10^9/L，不需要 GA。在构建的算法之后，应用决策辅助工具来评估风险和获益，在某些情况下，如果血小板计数指示但不可用，临床医生可能有理由选择 SA。
