Idiopathic Thrombocytopenic Purpura - ITP
Background
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ITP is an acquired thrombocytopenia caused by autoantibodies against platelet antigens
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ITT is a diagnosis of exclusion: one must exclude all other causes of nonimmune and immune platelet destruction, in a patient with isolated thrombocytopenia.
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The goal of treatment in a non-surgical setting is not to normalize platelets, but rather to prevent significant bleeding
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Critical bleeding events are treated with platelets transfusions, and glucocorticoids (typically, pulse dexamethasone) plus intravenous immune globulin (IVIG)
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Severe bleeding events are treated with glucocorticoids
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Therapies for refractor cases: Rituximab, TPO receptor agonist, and Splenectomy
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Considerations
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↑ Risk of surgical bleeding and the need for a specific platelet count for surgery:
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Hematology involvement is recommended
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Platelet threshold discussion with surgeon, but generally keep platelets >50,000/microL for major surgery and >100,000/microL for neurosurgery
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Platelets transfusions may be needed in emergency surgery
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Steroids, IVIG, or a TPO receptor agonist like romiplostim can be used to help raise the platelet count
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Neuraxial anesthesia considerations:
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The exact platelet level for performing spinal and epidural techniques is controversial and varies by clinician
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Generally, ITP patients may be safe to receive neuraxial anesthesia if the platelet count is >70,000/microL.
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Neuraxial anesthesia may be acceptable in patients with platelet counts between 50,000-70,000/microL where the risk:benefit analysis favors a neuraxial approach
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Neuraxial anesthesia is contraindicated in those with platelet counts <50,000/microL
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Considerations of medications a patient with ITP may be receiving
References
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Adriana OD. Hematologic disorders. In: Hines R, Jones S, editors. In: Stoelting's Anesthesia and Co-Existing Disease. 8th Edition. Philadelphia, PA: Elsevier; 2021. p. 465-496.