ITP and steroids in surgical candidate

Question 1

A 36 year old woman is to have a repair of a shoulder rotator cuff injury. She has a history of ITP and is on oral prednisone. How would you manage her?

Answer 1

Introductory
Main issues to address in this case;
- ITP and concomitant intraoperative risk of bleeding
- Chronic steroid use and risks to wound healing + risk of Addisonian crisis in setting of adrenal suppression; potential need for stress dosing for the procedure
- Appropriate counselling with patient prior to procedure for informed consent, discussion with treating team about course of management, input for haem and anaesthetics

Question 2

ITP and steroids - History and Exam

Answer 2

History

• characterise history of bleeding, degree of trauma associated, bruising
• dose and regularity of steroid medication, duration of use (~7mg is considered physiological, above would need to manage for addisonian crisis)
• SNAP: smoking and alcohol also impact wound healing

Exam

• General inspection, vitals
• petechiae, purpura, eccymosis
• evidence of cushings syndrome (moon facies, central adiposity, striae, ulcers, cataracts, acne, hirsuitism, etc)

Question 3

ITP and steroids - Investigations

Answer 3

Investigations
Key
- FBC: Thrombocytopenia, WCC
- <10 will bleed almost spontaneously
- 10-50: will bleed with minor trauma
- >100, likely appropriate for surgery
- Other pre-operative bloods: coags, UEC, G+H

Could also consider ACTH stimulation test to determine whether patient has adequate physiological reserve of adrenal gland function prior to surgery;

• administer synthetic ACTH
• measure serum cortisol at 30mins post adminstration; should see an adequate rise in cortisol of >18mcg.

Question 4

ITP and steroids - Management

Answer 4

Management
- pre-admissions for effective management

Counselling and consent
- go through consent process utilising I PRAC structure. Explain increased risks of surgery posed by ITP and steroid use, weigh up with benefits of surgery. Can it be delayed? need to have this in discussion with rest of treating team as to the appropriate medical advice to be relayed to the patient to allow for them to make an informed decision.

Thrombocytopenia;

• given an autoimmune process, patient will require administration of platelets prior to surgical procedure. Aim >50’000 given immediate and ongoing destructive process that occurs
• Administer platelets in pre-op room right before operation
• otherwise, can course of prednisone be completed and platelets observed to have normalised, and surgery be delayed?

Addisonian crisis

• If there is no evidence/risk of adrenal suppression based on the patients regular dose, then proceed with surgery without the stress dose.
• otherwise, if suppression is evident or dose of pred is high enough to suspect, then will need to administer a stress dose of prednisone, usually 2-3x the regular dose
• taper down to normal dose of 2-3 days post-operative
• monitor for signs of adrenal insufficiency (vomiting, nausea, hypotension, hyponatraemia, hyperkalaemia, altered mental state); if present then increase pred dosing.