|Year : 2018 | Volume
| Issue : 3 | Page : 42-44
Intraoperative thromboelastographic assessment of platelet function in a patient with low platelet count and high-mean platelet volume requiring cardiac surgery
Francesco Del Sindaco, Daniel Rajeev, Sandra Faloye, Lisa Vipond
Department of Anaesthesia, Royal Brompton Hospital, Sydney Street, London, UK
|Date of Submission||31-Dec-2019|
|Date of Acceptance||29-Oct-2018|
|Date of Web Publication||24-May-2019|
Francesco Del Sindaco
Royal Brompton Hospital, Sydney Street, London, SW3 6NP
Source of Support: None, Conflict of Interest: None
An 80-year-old patient with low platelet count was admitted in our institution for aortic valve replacement and a coronary artery bypass graft. Because of thrombocytopenia, a mean platelet volume has been assessed, showing a value above the range. Two pools of platelets were booked but not transfused, neither in the theater nor during the postoperative period. A thromboelastographic assessment at the end of the cardiopulmonary bypass showed a normal overall platelet function, and no clinical issues (diffuse bleeding after protamine and/or oozing from the drain above the range, in the postoperative period) were noticed. The authors point out the importance of thromboelastographic or thromboelastometric assessments in patients with isolated thrombocytopenia and high-mean platelet volume to contribute to reduce the risk of inappropriate transfusions.
Keywords: cardiac surgery, platelets, thromboelastography, transfusion
|How to cite this article:|
Sindaco FD, Rajeev D, Faloye S, Vipond L. Intraoperative thromboelastographic assessment of platelet function in a patient with low platelet count and high-mean platelet volume requiring cardiac surgery. Egypt J Cardiothorac Anesth 2018;12:42-4
|How to cite this URL:|
Sindaco FD, Rajeev D, Faloye S, Vipond L. Intraoperative thromboelastographic assessment of platelet function in a patient with low platelet count and high-mean platelet volume requiring cardiac surgery. Egypt J Cardiothorac Anesth [serial online] 2018 [cited 2019 Jun 18];12:42-4. Available from: http://www.ejca.eg.net/text.asp?2018/12/3/42/258994
| Introduction|| |
The correlation between low platelet count and high-mean platelet volume (MPV), in some patients, is well known and studied ,,,. A larger MPV can often counteract a lower number of platelets, resulting in their normal global activity in the hemostatic process. Automatic platelet count devices, for technical reasons, sometimes are unable to detect such large cells and to recognize them as platelets, leading to a further underestimation of their number .
In cardiac surgery, in such cases, the main questions are as follows:
- Will the larger volume be able to compensate for the low number of platelets?
- Should we have to book platelets to have them promptly available and should we decide about transfusion on the basis of clinical assessment supported by point of care tests?
- Should we transfuse the patients in anyway?
- Should we postpone the surgery?
Unfortunately, MPV is often not provided, on a routine basis, by some laboratories, making the risk of superfluous platelet transfusions or procedure cancellation more probable. A reliable assessment of platelets’ overall function is desirable to contribute to avoid these potential risks.
An 80-year-old man was scheduled for aortic valve replacement owing to severe aortic valve stenosis and coronary artery bypass graft for a critical stenosis of the right coronary artery. The preoperative platelet count was 84×109/l, which is below our institution threshold for adult cardiac surgery (100 000×109/l). Because of this, a MPV assessment was performed, showing a value above the normal range (6.8–10.1 fl). The hematological advice, therefore, was to book two pools of platelets, to be transfused in case of diffuse bleeding due not to other detected reasons. As the patient was on regular aspirin, suspended 7 days before the surgery, a multiplate test (Multiplate Analyzer; Roche Diagnostics International Ltd, Rotkreuz, Switzerland) was requested to rule out any residual effect of the drug. Thromboxane A2 receptors were not blocked by aspirin: ASPI test 115 U (range: 71–115 U).
Before starting the CPB, 3000 mg of intravenous tranexamic acid as a bolus dose and 25 000 units of heparin intravenously were administered.
During the rewarming time of the CPB, at 35°C, a thromboelastogram (TEG; Hemoscope Corporation, Niles, Illinois, USA) with kaolin and heparinase, and with abciximab and heparinase (functional fibrinogen), and a full blood count (Horiba ABX Micros ES 60; HORIBA Ltd, Kyoto, Japan) were performed.
The kaolin with heparinase and functional fibrinogen TEG diagrams are shown in the [Figure 1] and [Figure 2], respectively. As can be seen, all the parameters were in range, particularly the Heparinase TEG Maximum Amplitude (MA), which depends on fibrinogen, platelet number and factor XIII (58.3 mm; range: 54–72 mm). The platelet count was 55×109/l, and the MPV 10.6 fl. The blood cell counter device detected the presence of schistocytes on the counting zone of platelets, and abnormal number of cells in comparison with the lymphocytes in the 30–60 fl zone, probably owing to platelet aggregation. The CPB lasted 120 min, and the cross-clamping time was 85 min.
In the theater, after heparin full reversal, the patient did not show any clinical sign of coagulopathy, and supported by the results of the point of care tests performed at the end of the CPB, no platelets were transfused. During the postoperative period, the bleeding from the drains was below the value considered critical in our institution (250 ml/h and/or 50 ml/10 min) and neither platelets nor other blood products were transfused.
The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day.
| Discussion|| |
This case suggests an easy assessment of the overall hemostatic function of platelets in case of low cell count and high MPV. Despite a significant low platelet count, a normal MA in the thromboelastographic assessment could suggest an overall normal function of the platelets. This indicates that platelets, activated by thrombin in the TEG cuvette, although of lower number, could interact properly with other factors to achieve a normal clot firmness. TEG was not designed to assess platelet function (the available tests to assess, using different techniques, platelets function through viscoelastic essays need further studies to be fully validated) but just their number . Nevertheless, in this case, the MA of the TEG could suggest us the overall platelet activity in the hemostatic process. The cell counter device alarms could point to the existence of large platelets, but results were not conclusive. Based on the clinical observations and thanks to the TEG results, the patient did not receive any platelets and/or any other blood product during the entire perioperative period. A rewarming time or, better, a basal assessment can contribute in reducing inappropriate transfusions, and therefore, to lower the costs of the operations and to reduce the risks of transfusion-related complications, like transfusion-related acute lung injury or infection transmission, not negligible in case of room temperature-stored products such as platelets ,,.In conclusion, in case of isolated thrombocytopenia with high MPV, thromboelastography and thromboelastometry, are useful and easy tests to assess the overall platelets function and help to reduce the risks of transfusion-related cost and complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Klovaite J, Benn M, Yazdanyar S, Nordestgaard BG. High platelet volume and increased risk of myocardial infarction: 39 531 participants from the general population. J Thromb Haemost 2011; 9:49–56
Biino G, Portas L, Murgia F, Vaccargiu S, Parracciani D, Pirastu M, Balduini CL. A population-based study of an Italian genetic isolate reveals that mean platelet volume is not a risk factor for thrombosis. Thromb Res 2012; 129:e8–e13.
Vasse M, Masure A, Lenormand B. Mean platelet volume is highly correlated to platelet count. Thromb Res 2012; 130:559–560.
Panova-Noeva M, Schulz A, Hermanns MI, Gorssmann V, Pefani E, Spronk E et al.
Sex-specific differences in genetic and nongenetic determinants of mean platelet volume: results from the Gutenberg health study. Blood 2016; 127:251–259.
Balduini CL, Pecci A, Noris P. Inherited thrombocytopenias: the evolving spectrum. Hamostaseologie 2012; 32:259–270.
Paniccia R, Priora R, Liotta AA, Abbate R. Platelet Function tests: a comparative review. Vasc Health Risk Manag 2015; 11:133–148.
Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C et al.
2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88–120.
Katus MC, Szczepiorkowski ZM, Dumont LJ, Dunbar NM. Safety of platelet transfusion: Past, present and future. Vox Sang 2014; 107:103–113.
Peters AL, Vlaar APJ. Redefining transfusion-related acute lung injury: don’t throw the baby out with the bathwater. Transfusion 2016; 56:2384–2388.
[Figure 1], [Figure 2]