In Thrombocytopenic Patients:
Splenectomy in thrombocytopenic patients generally
involves one of two clinical situations:
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.
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
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
|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
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.
transfusions to maintain hemostasis in thrombocytopenic splenectomy
patients should not be initiated until splenic vessels are
platelet transfusion should then be given rapidly. Effective
hemostasis will generally be achieved.
John B., Director of Clinical Laboratories, The Lexington
Medical Center, West Columbia, S. C., Aug. 2001.
August 2001; latest addition 3 November 2004)
1999 - 2006, all rights reserved, Pathology Associates Of Lexington,