Pathology Associates Of Lexington, P.A.

Splenectomy In Thrombocytopenic Patients:

TRANSFUSION GUIDELINES

Splenectomy in thrombocytopenic patients generally involves one of two clinical situations:

1. Idiopathic thrombocytopenic purpura (ITP) in which antiplatelet antibodies cause sequestration of platelets within the spleen. The spleen is most often normal size or minimally enlarged. Patients not responding to steroid therapy often respond to splenectomy with return of platelet counts to normal or near normal ranges.

2. Hyper-splenic syndrome due to a variety of situations in which an enlarged spleen causes entrapment of platelets (often also entrapment of WBCs and RBCs): hyper-splenic patients are often pancytopenic. Enlargement due to cirrhosis or non-cirrhotic causes.

As splenectomy may be beneficial in both these situations, one of the surgical challenges is that of maintaining operative hemostasis in patients with a severely depleted platelet count. In these platelet-consumption, thrombocytopenic situations, platelets tend to be newly released, hyper-effective or “sticky” and more hemostatically effective than the low platelet count would suggest...more effective than low platelet counts due to marrow suppression.

Platelet transfusions given prior to splenectomy will simply result in the infused platelets being entrapped in the spleen with no clinical or hemostatic benefit. That this entrapment of transfused platelets can occur very quickly is evidenced by the inability to document an increased post-transfusion platelet count in these patients. This results in a waste of critical platelet units with no clinical benefit.

Therefore platelet transfusions, which are occasionally necessary to maintain hemostasis during surgery, should not be given (started) while blood is perfusing the spleen. Platelet transfusions in these situations can and should be started as soon as the splenic vessels are ligated.

A significant number of thrombocytopenic splenectomy patients will not bleed spontaneously. Hemostatic problems are heralded by diffuse oozing and failure to form blood clots within the operative field. When deemed necessary to maintain hemostasis in thrombocytopenic splenectomy patients, a single 8-10 unit platelet apheresis pack is generally sufficient therapy. A post-op platelet count will document whether or not the thrombocytopenia is correcting. Further transfusions can be given as necessary.

RBC transfusions should be given only as necessary to correct significant anemia in these situations.

FFP transfusions should be given only as necessary to correct plasma coagulation factor deficiencies reflected by prolonged PT and/or PTT. This can be anticipated in cases with chronic liver disease.

SUMMARY

Platelet transfusions to maintain hemostasis in thrombocytopenic splenectomy patients should not be initiated until splenic vessels are ligated. Necessary platelet transfusion should then be given rapidly. Effective hemostasis will generally be achieved.

References:

Carter, John B., Director of Clinical Laboratories, The Lexington Medical Center, West Columbia, S. C., Aug. 2001.

(posted August 2001; latest addition 3 November 2004)