Thread by @OBsleepmerchant

@SOAPHQ and @ASRA_Society joint panel: A tailored approach to the management of the thrombocytopenic patient. With Dr Roulhac Toledano MD moderating Dr Lisa Leffert MD, @MelissaEBauer1 and @dr_melissabyrne

@MelissaEBauer1 (@DukeAnesAlumni) kicks off @SOAPHQ @ASRA_Society joint session: How low can you go? Looking at recent @SOAPHQ consensus statement. #SOAPAM2023

With acknowledgment that #OBAnes airway may be difficult, the use of neuraxial with lower platelet counts. 2015 sees rapid increase in literature supporting placement below 100,000. However, @SOAPHQ members requested a consensus statement as institutional policies were slow to… twitter.com/i/web/status/1…

A modified Delphi process. A lot of these procedures were lumbar punctures. < 25,000 - a lot of societies recommend platelet cover, IR and LP performed procedures. #SOAPAM2023

26-50,000 no cases; 51-75,000 9 cases but some has other reasons to bleed than platelet count; 75-100,000 4 cases, similarly other reasons to bleed. More scary: asymptomatic patients #SOAPAM2023

Every case was included even if on history it was unlikely related to the neuraxial/ platelet count #SOAPAM2023

Most common signs & symptoms. Lower extremity motor deficit easy. However, don’t forget to ask about urinary & bowel symptoms. #SOAPAM2023

Definitions of thrombocytopenia. ITP superplatelets - strongly held belief, no clear evidence. Preeclampsia: if NOT in HELLP, platelet function is not drastically different. #SOAPAM2023

Must ask about current signs of bleeding. How you ask the question is important - simply asking about heavy periods and bruising will steer you wrong! If asked that way, people with normal coagulation answer yes. #SOAPAM2023

The bleeding history assessment has specific guidance. Note heavy periods and easy bruising have defined parameters. #SOAPAM2023

The algorithm. #SOAPAM2023

If unsure, be cautious. Could not specifically delineate spinal vs epidural recommendations. Majority of cases included = LP (green) [ consider vs Anesthesia (red)] #SOAPAM2023

Strategies to reduce risk! JFK quote applicable to #OBAnes (and #AnyAnes)

@SOAPHQ @ASRA_Society (and @ESRA_Society @OAAinfo @docanaesthetic @ANZCA etc ) members to join/ contribute to international registry on ITP & #OBAnes neuraxial at low platelets. #SOAPAM2023

Moving on to 2nd lecture of @SOAPHQ @ASRA_Society joint session at #SOAPAM2023 with Dr Lisa Leffert MD hoping for knowledge consolidation with a selection of #OBAnes cases.

1st case.#SOAPAM2023

Guidance exists that in the absence of comorbidities/ significant history, routine platelet counts are not required. We can take solace from the fact that while platelet count does drop during pregnancy, it seldom drops too low. #SOAPAM2023

Next case: ITP. Superplatelets seem to be a myth. Yes case reports exist (platelet count NOT know prior to CSE for labour analgesia) @maloumeng @ruthi_landau - BUT on the whole platelet function in ITP is consistent over time independent of count. #SOAPAM2023

Case 3. Preeclampsia - no evidence UNLESS patient has HELLP syndrome #SOAPAM2023

Case 4. What does consensus statement say about neuraxial below 70,000? Data limited. Risk benefit balance. #SOAPAM2023

Bleeding questions require nuance, and context. @MelissaEBauer1 example: patient with multiple bruises who on questioning reveals they have an excitable big puppy that jumps on them everyday until fed ≠ bleeding disorder (3-5year old kids have similar effects tbh) #SOAPAM2023

Next case: platelets of 60,000. Most of our data based on LP rather than #OBAnes - cannot make clear recommendation #SOAPAM2023

Most guidelines do NOT recommend platelet transfusion at 60,000. Context is important though. #SOAPAM2023

Is a labor epidural elective? What dictates decision? Patient autonomy vs medical indications vs fetal indications? Self awareness of what factors impact your choice to proceed is important. Summary slide from Dr Lisa Leffert, MD #SOAPAM2023

And continuing @SOAPHQ @ASRA_Society joint session with @dr_melissabyrne: Thrombocytopenia and PNB: Delivering Safer Care. #SOAPAM2023 #OBAnes

Learning objectives. Did you know? Not all pregnant women needing #OBAnes care are in labour? #SOAPAM2023

Facts to understand. 2% of pregnant patients (80,000) undergo anesthesia every year. 1 in 8 of OB patients have thrombocytopenia. Luckily only 1% have platelets < 100,000 #OBAnes #SOAPAM2023

Prioritize #patientsafety. Some History: first statement on neuraxial and anticoagulation management/ timing in 1998. Some progress along the way, adding #OBAnes patients in 2003 and expanding recommendations in 2010. @SOAPHQ consensus statement 2017. Last @ASRA_Society consensus… twitter.com/i/web/status/1…

That said the new @ASRA_Society guideline due soon - stay tuned. #SOAPAM2023

Mandatory @ASRA_Society disclaimer: guidelines ≠ standard of care, not replace clinical judgement, variances acceptable. Guidelines designed to encourage safe and quality patient care #SOAPAM2023

Antithrombotic therapy and pregnancy. VTE one of most common causes OB M&M. VTE prophylaxis decreased morbidity BUT increase bleeding. Plexus & PNB in anticoagulated patient: what do we know? What deters is? What is missing? #SOAPAM2023

There’s a whole lot more we don’t know than what we do. The more we do know, seemingly the less we have answers for? #SOAPAM2023

What we (sorta) know: continuous femoral catheters while receiving rivvaroxaban - no hematomas observed; 32 patients reasonable mix between group on antithrombotic therapy and group without - NO definitive recommendations. #SOAPAM2023

We know knowledge acquisition is a winding path. The most serious complication is bleeding, not neurological. Major morbidity is what we cannot see. We know it’s not from single direct vessel puncture, but rather difficult needling / catheter placement. #SOAPAM2023

Recommendations. Old and new. #SOAPAM2023

DISCLAIMER: @ASRA_Society recommendations are for neuraxials, and do NOT include platelet counts. #SOAPAM2023

Sadly this leaves us between a rock and a hard place. DISCLAIMER. @dr_melissabyrne heads into the realm of opinion, oh my! #OBAnes #SOAPAM2023

Lesson 3. Risks vs benefits. Literature is a maze… probably more likely a mine field? Several PNB have been performed on patients on anticoagulants or antiplatelets, without complications. #SOAPAM2023

Systematic review reveals 80 bleeding complications in 9,738 PNB (0.82% overall incidence). Lumbar plexus most risky. 1 death. @Assoc_Anaes @OAAinfo @RegionalAnaesUK guidelines stratify risk. @BJAJournals list 6 special considerations: hemophilias, major trauma/ massive… twitter.com/i/web/status/1…

Controversy: Practice advisory in @CJA_Journal proposes bleeding risk score system based on expert panel consensus and literature review. #SOAPAM2023

@SLKoppMD & co express concerns, including unvalidated scoring system, inconsistent methodology, lack of true consensus on majority of blocks. Rebuttal & reply lead based on shared goal, weigh risks and benefits, collaboration. Middle ground found. #SOAPAM2023

PNB in patients on antithrombotics: a rescue or unnecessary risk? How to approach these patients: weigh risk vs benefit, consider indication for block. Differing conclusions vs @ASRA_Society recommendations. Regarding thrombocytopenia: rare recommendation - >75,000 adequate… twitter.com/i/web/status/1…

Lesson #4: existing guidelines offer useful principles to help practice. A personal disclosure from @dr_melissabyrne: she has a dark cloud when on call. #SOAPAM2023

A typical start to a call? Pain management consult. G1P0 35+5 ORIF distal radius. Gestational thrombocytopenia: platelets 73,000. What is your plan? #OBAnes #SOAPAM2023

Hahahaha the voice in #OBAnes head can be very loud. Organize your environment to boost sense of control. Remember: @ASRA_Society guidelines. A lot of factors to be considered. #OBAnes #SOAPAM2023

Supraclavicular block is out - vessels, potentially difficult compression. Infraclavicular block similarly undesirable. #OBAnes #SOAPAM2023

Axillary block favourable - easier compression artery and vein. Remember to follow up with the patient. Majority of Twitter agreed - see discussions on @dr_melissabyrne’s profile. #OBAnes #SOAPAM2023

Next page. Urgent cesarean section. Platelets 68,000. What’s your plan? #OBAnes #SOAPAM2023

Ah-ha changing goal posts - patient refusing a neuraxial (that I suspect most #OBAnes would have been comfortable giving her). H/o ileus, multiple abdominal surgeries. NOW what is your plan? #SOAPAM2023

Options for postop analgesia. Some immediately removed. Local wound infiltration always an option (although favour PROSPECT type - requires surgical training) #OBAnes #SOAPAM2023

Ilioinguinal and iliohypogastric not preferred, as may as well perform a more effective TAP block? TAP is effective when ITM not possible/ desired. #OBAnes #SOAPAM2023

What about QLB? It does reduce pain scores. @elboghdadly et al (incl @PervezSultanMD) found TAP & QLB effective for postoperative pain when ITM not possible/desired #OBAnes #SOAPAM2023

Thinking critically about QLB though: deep, site not necessarily compressible. QLB perhaps not best choice. #OBAnes #SOAPAM2023

So TAP best of options. Remember Follow -up with patient. Twitter poll a little bit closer, but see discussion on @dr_melissabyrne’s profile #OBAnes #SOAPAM2023

Next page: epidural request. G1P0 39+3 elective induction. ITP. SUD Hx on suboxone. Platelets 45,000. What is your anesthetic plan? #OBAnes #SOAPAM2023

Does removing suboxone change your plan? #OBAnes #SOAPAM2023

Bilateral ESP for labour analgesia? Options for cesarean would be as discussed. ESP block has potential? @IJOA_Journal (If you believe it works @Steve_Coppens @KalagaraHari @NarouzeMD @amit_pawa?) #OBAnes #SOAPAM2023

Anatomical examination of spread @CJA_Journal - suggests may be adequate. @Anaes_Reports has case series of 4 women in active labour. Decreased pain. Short duration. Long enough if well timed? A potential catheter technique? #OBAnes #SOAPAM2023

ESP block a viable labour analgesia option. Remember follow-up. #OBAnes #SOAPAM2023

For cesarean section, we have options. @Anaes_Journal published update on PROSPECT guidance. TAP, QLB and ESP all accepted if ITM not possible/ desirable. Twitter, however, favoured remifentanil PCA. Discussions on @dr_melissabyrne’s profile. #OBanes #SOAPAM2023

And what of the future? #SOAPAM2023

Lesson #5: Tailored care can aid clinical decision making. One size does NOT fit all. (Echoes of @HansSviggum @bscottsegal protocolized care debate elsewhere on my profile) #OBAnes #SOAPAM2023

Standard approach of 1 technique for disparate groups gets variable results. Tailoring different approaches for different populations decrease pain scores. However, tailoring risk appropriately (in accordance with benefit) may decrease complication rates (pain scores no longer… twitter.com/i/web/status/1…

Final Lesson: let’s aim to deliver safer care. Summary slide from @dr_melissabyrne. Scan QR code for references. #OBAnes #SOAPAM2023

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