Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Lumbar punctures in thrombocytopenic children with cancer Mirella V. Foerster, Francisco de Paula Ramos Pedrosa, Tereza Cristina Teixeira da Fonseca, ^nia Cursino de Menezes Couceiro & Luciana C. Lima Ta Anesthesiology, Oncology, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
Keywords spinal puncture; thrombocytopenia; subdural spinal hematoma; child; anesthesia; complications Correspodence Mirella Vilas Foerster, Anesthesiology, “Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)”, “Rua dos Coelhos”, Recife, CEP:50070-550, Brazil Email: [email protected] Section Editor: Adrian Bosenberg Accepted 14 August 2014 doi:10.1111/pan.12527
Summary Introduction: Lumbar punctures (LP) in patients presenting thrombocytopenia are linked to the possibility of bleeding and spinal hematomas. The minimum platelet count required for the safe performance of spinal procedures is still under discussion. Children with some oncology diseases require routinely lumbar punctures; such patients often present thrombocytopenia, making this group an ideal population to study the association between lumbar puncture in thrombocytopenic patients and complications. Objectives: To determine the platelet count of oncology children undergone lumbar punctures and the occurrence of spinal hematomas. Method: Observational longitudinal study. It included a retrospective analysis of electronic medical records of oncology patients submitted to LP for intrathecal chemotherapy between January 2004 and October 2011, carried out at the ‘Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)’, Recife, Brazil. Results: We evaluated 9088 lumbar punctures performed in 440 patients. The platelet count distribution before lumbar punctures was as follows: 25 punctures had zero to 10 000 platelets per mm3, 67 punctures had between 10 000 and 20 000 platelets per mm3, 88 had between 20 000 and 30 000 platelets per mm3, 92 punctures had between 30 000 and 40 000 platelets per mm3, 107 punctures had between 40 000 and 50 000 platelets per mm3, and 729 punctures had between 50 000 and 100 000 platelets per mm3. In this series, the incidence of bloody tap was 16.9% (1112 lumbar punctures of 6552 had more than ten erythrocytes). No complications were observed. Conclusions: Even in thrombocytopenic patient, an epidural hematoma would be a relatively rare complication following lumbar puncture. Despite the large number of punctures performed on patients with platelet counts below 100 000 mm 3 (n = 1108), further studies are necessary in order to determine a lower safe platelet count threshold for the performance of lumbar punctures in healthy patients undergoing neuraxial anesthesia.
Introduction Lumbar punctures for diagnosis, therapy, or anesthesia are common and safe procedures. However, there can be complications, such as spinal hematomas (1). Their clinical importance stems from the fact that if not 206
diagnosed and treated in a timely fashion, its acute progressive course can lead to death or to permanent neurological damage (2,3). In the general population, the current risk of spinal hematomas associated with epidural anesthesia is estimated as 1 : 150 000, while the risk associated with © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 206–210
M.V. Foerster et al.
spinal anesthesia is estimated as 1 : 220 000 (1,2). There are studies that describe the incidence to be as high as 1 : 3.600 (4). Based on studies about bleeding times (BT), Cousins and Bromage have recommended that epidural or spinal punctures should be avoided in patients whose platelet count has fallen below 100 000 mm 3 (5). Studies performed in 2009 (5,6) actually question this recommendation and suggest that it is possible to perform epidural and/or spinal punctures even with platelet levels below 40 000 mm 3. Children suffering from oncology diseases have to undergo lumbar punctures for the diagnosis of nervous system illnesses or for the application of prophylactic intrathecal chemotherapy (7). Seventy-five percent of children with acute leukemia present a platelet count lower than 100 000 mm 3, at the point of diagnosis. In order to reduce the risk of hemorrhages as well as of neurological complications, the British Committee for Standards in Haematology (BCSH) recommends the performance of prophylactic platelet transfusions prior to lumbar punctures when the platelet count is lower than 40 000 mm 3 in children. At IMIP, only children that undergo lumbar punctures for diagnosis (first puncture) and that, at that point, present a platelet count lower than 50 000 mm 3 are submitted to platelet transfusion. This is done to reduce the risk of traumatic tap and bleeding in the CSF and the resulting contamination of the CNS by leukemic cells, which could lead to a modification of protocol, with the treatment being intensified. In our study, diagnostic punctures were excluded. Recently, researchers have begun to question the possibility of performing lumbar punctures in patients that present platelet counts lower than the thresholds mentioned above, but for whom the benefits of such procedures outweigh the risks of spinal hematomas – examples of such cases are children with oncology diseases (6). The present study aimed to determine the platelet count in pediatric oncology patients who have undergone lumbar puncture and to study the occurrence of spinal hematoma. Method After we obtained the approval of the institution’s Ethics in Research with Human Beings Committee, we carried out a cross-sectional observation study. It consisted of a retrospective analysis of electronic health records of pediatric oncology patients who were registered and monitored at the Integral Medicine Institute Prof. Fernando Figueira (IMIP). The aforementioned patients had all undergone lumbar punctures. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 206–210
Thrombocytopenic children with cancer
The study’s inclusion criteria were the following: children with oncology diseases who had undergone lumbar punctures for diagnosing CNS infiltration and administration of prophylactic intrathecal chemotherapy; patients up to 18 years of age at the time of diagnosis; and registered patients at the Pediatric Oncology Centre with electronic health records between January 2004 and October 2011. Initial diagnostic lumbar punctures as well as lumbar punctures without a previous platelet count were excluded from the study for the following reasons. At IMIP, children that undergo lumbar punctures for diagnosis (first puncture) and present with a platelet count lower than 50 000 mm 3 receive platelet transfusion. Prior to the lumbar puncture, a blood sample was collected for platelet count. This was done using an automated measuring device, called a Coulter counter (MAXM Sysmex-xt 1800i). All lumbar punctures were performed either by an onco-hematologist or by a second-year resident in pediatric oncology. Patients were either under general anesthesia or awake under local anesthesia, if there was some contraindication for general anesthesia, for example, those at risk of pulmonary aspiration of gastric content. Children were positioned on left lateral decubitus, and the punctures were performed with a 22-gauge Quincke needle. After collecting 12 to 20 drops of CSF for analysis, prophylactic intrathecal chemotherapy was performed. Especially in cases of tap bloody, parents should be vigilant for symptoms such as focal motor deficit, abnormal posturing, and urinary retention (although less frequent). Patients seen in the clinic should be admitted immediately to the hospital. Relevant data were collected by the researchers, who completed forms with information obtained from the Electronic Health Records. Sex, age, cancer diagnosis, and number of lumbar punctures performed in each child were recorded, so that the epidemiological and clinical profiles could be described. Furthermore, the researchers also recorded the frequency distributions by platelet count groups (zero—50 000 mm 3, 50 000— 100 000 mm 3, and over 100 000 mm 3) as well as the occurrence of spinal hematoma (confirmed both by clinical criteria and by CT scan and nuclear magnetic resonance of the neuraxis). EPI INFO software, version 3.5.3 (Centers for Disease Control and Prevention CDC, 2011) was used to analyze the data collected. Results We evaluated 9088 lumbar punctures, performed in 440 patients. Among those, we found a median of 15 lumbar punctures, varying from 1 to 75 punctures per patient, 207
M.V. Foerster et al.
Thrombocytopenic children with cancer
between January 2004 and October 2011. The average patient age was 7.8 years, with a minimum of 1 month and maximum of 20.9 years. Patients up to 18 years of age at the time of diagnosis were included in the study. Because some treatment protocols last for over 2 years, one can find in the analysis patients who were over 18 years of age when undergoing lumbar punctures. Among the patients, 175 (39.4%) were female and 269 (60.6%) were male. The most frequent diagnosis found in the lumbar punctures was acute lymphoid leukemia (83.3%). Table 1 shows the epidemiological profile according to the diagnosis of all patients included in the study. The number of lumbar punctures according to the platelet count distribution per group prior to the procedures was as follows: 379 in patients whose count was
ORIGINAL ARTICLE
Lumbar punctures in thrombocytopenic children with cancer Mirella V. Foerster, Francisco de Paula Ramos Pedrosa, Tereza Cristina Teixeira da Fonseca, ^nia Cursino de Menezes Couceiro & Luciana C. Lima Ta Anesthesiology, Oncology, Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil
Keywords spinal puncture; thrombocytopenia; subdural spinal hematoma; child; anesthesia; complications Correspodence Mirella Vilas Foerster, Anesthesiology, “Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)”, “Rua dos Coelhos”, Recife, CEP:50070-550, Brazil Email: [email protected] Section Editor: Adrian Bosenberg Accepted 14 August 2014 doi:10.1111/pan.12527
Summary Introduction: Lumbar punctures (LP) in patients presenting thrombocytopenia are linked to the possibility of bleeding and spinal hematomas. The minimum platelet count required for the safe performance of spinal procedures is still under discussion. Children with some oncology diseases require routinely lumbar punctures; such patients often present thrombocytopenia, making this group an ideal population to study the association between lumbar puncture in thrombocytopenic patients and complications. Objectives: To determine the platelet count of oncology children undergone lumbar punctures and the occurrence of spinal hematomas. Method: Observational longitudinal study. It included a retrospective analysis of electronic medical records of oncology patients submitted to LP for intrathecal chemotherapy between January 2004 and October 2011, carried out at the ‘Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)’, Recife, Brazil. Results: We evaluated 9088 lumbar punctures performed in 440 patients. The platelet count distribution before lumbar punctures was as follows: 25 punctures had zero to 10 000 platelets per mm3, 67 punctures had between 10 000 and 20 000 platelets per mm3, 88 had between 20 000 and 30 000 platelets per mm3, 92 punctures had between 30 000 and 40 000 platelets per mm3, 107 punctures had between 40 000 and 50 000 platelets per mm3, and 729 punctures had between 50 000 and 100 000 platelets per mm3. In this series, the incidence of bloody tap was 16.9% (1112 lumbar punctures of 6552 had more than ten erythrocytes). No complications were observed. Conclusions: Even in thrombocytopenic patient, an epidural hematoma would be a relatively rare complication following lumbar puncture. Despite the large number of punctures performed on patients with platelet counts below 100 000 mm 3 (n = 1108), further studies are necessary in order to determine a lower safe platelet count threshold for the performance of lumbar punctures in healthy patients undergoing neuraxial anesthesia.
Introduction Lumbar punctures for diagnosis, therapy, or anesthesia are common and safe procedures. However, there can be complications, such as spinal hematomas (1). Their clinical importance stems from the fact that if not 206
diagnosed and treated in a timely fashion, its acute progressive course can lead to death or to permanent neurological damage (2,3). In the general population, the current risk of spinal hematomas associated with epidural anesthesia is estimated as 1 : 150 000, while the risk associated with © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 206–210
M.V. Foerster et al.
spinal anesthesia is estimated as 1 : 220 000 (1,2). There are studies that describe the incidence to be as high as 1 : 3.600 (4). Based on studies about bleeding times (BT), Cousins and Bromage have recommended that epidural or spinal punctures should be avoided in patients whose platelet count has fallen below 100 000 mm 3 (5). Studies performed in 2009 (5,6) actually question this recommendation and suggest that it is possible to perform epidural and/or spinal punctures even with platelet levels below 40 000 mm 3. Children suffering from oncology diseases have to undergo lumbar punctures for the diagnosis of nervous system illnesses or for the application of prophylactic intrathecal chemotherapy (7). Seventy-five percent of children with acute leukemia present a platelet count lower than 100 000 mm 3, at the point of diagnosis. In order to reduce the risk of hemorrhages as well as of neurological complications, the British Committee for Standards in Haematology (BCSH) recommends the performance of prophylactic platelet transfusions prior to lumbar punctures when the platelet count is lower than 40 000 mm 3 in children. At IMIP, only children that undergo lumbar punctures for diagnosis (first puncture) and that, at that point, present a platelet count lower than 50 000 mm 3 are submitted to platelet transfusion. This is done to reduce the risk of traumatic tap and bleeding in the CSF and the resulting contamination of the CNS by leukemic cells, which could lead to a modification of protocol, with the treatment being intensified. In our study, diagnostic punctures were excluded. Recently, researchers have begun to question the possibility of performing lumbar punctures in patients that present platelet counts lower than the thresholds mentioned above, but for whom the benefits of such procedures outweigh the risks of spinal hematomas – examples of such cases are children with oncology diseases (6). The present study aimed to determine the platelet count in pediatric oncology patients who have undergone lumbar puncture and to study the occurrence of spinal hematoma. Method After we obtained the approval of the institution’s Ethics in Research with Human Beings Committee, we carried out a cross-sectional observation study. It consisted of a retrospective analysis of electronic health records of pediatric oncology patients who were registered and monitored at the Integral Medicine Institute Prof. Fernando Figueira (IMIP). The aforementioned patients had all undergone lumbar punctures. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 25 (2015) 206–210
Thrombocytopenic children with cancer
The study’s inclusion criteria were the following: children with oncology diseases who had undergone lumbar punctures for diagnosing CNS infiltration and administration of prophylactic intrathecal chemotherapy; patients up to 18 years of age at the time of diagnosis; and registered patients at the Pediatric Oncology Centre with electronic health records between January 2004 and October 2011. Initial diagnostic lumbar punctures as well as lumbar punctures without a previous platelet count were excluded from the study for the following reasons. At IMIP, children that undergo lumbar punctures for diagnosis (first puncture) and present with a platelet count lower than 50 000 mm 3 receive platelet transfusion. Prior to the lumbar puncture, a blood sample was collected for platelet count. This was done using an automated measuring device, called a Coulter counter (MAXM Sysmex-xt 1800i). All lumbar punctures were performed either by an onco-hematologist or by a second-year resident in pediatric oncology. Patients were either under general anesthesia or awake under local anesthesia, if there was some contraindication for general anesthesia, for example, those at risk of pulmonary aspiration of gastric content. Children were positioned on left lateral decubitus, and the punctures were performed with a 22-gauge Quincke needle. After collecting 12 to 20 drops of CSF for analysis, prophylactic intrathecal chemotherapy was performed. Especially in cases of tap bloody, parents should be vigilant for symptoms such as focal motor deficit, abnormal posturing, and urinary retention (although less frequent). Patients seen in the clinic should be admitted immediately to the hospital. Relevant data were collected by the researchers, who completed forms with information obtained from the Electronic Health Records. Sex, age, cancer diagnosis, and number of lumbar punctures performed in each child were recorded, so that the epidemiological and clinical profiles could be described. Furthermore, the researchers also recorded the frequency distributions by platelet count groups (zero—50 000 mm 3, 50 000— 100 000 mm 3, and over 100 000 mm 3) as well as the occurrence of spinal hematoma (confirmed both by clinical criteria and by CT scan and nuclear magnetic resonance of the neuraxis). EPI INFO software, version 3.5.3 (Centers for Disease Control and Prevention CDC, 2011) was used to analyze the data collected. Results We evaluated 9088 lumbar punctures, performed in 440 patients. Among those, we found a median of 15 lumbar punctures, varying from 1 to 75 punctures per patient, 207
M.V. Foerster et al.
Thrombocytopenic children with cancer
between January 2004 and October 2011. The average patient age was 7.8 years, with a minimum of 1 month and maximum of 20.9 years. Patients up to 18 years of age at the time of diagnosis were included in the study. Because some treatment protocols last for over 2 years, one can find in the analysis patients who were over 18 years of age when undergoing lumbar punctures. Among the patients, 175 (39.4%) were female and 269 (60.6%) were male. The most frequent diagnosis found in the lumbar punctures was acute lymphoid leukemia (83.3%). Table 1 shows the epidemiological profile according to the diagnosis of all patients included in the study. The number of lumbar punctures according to the platelet count distribution per group prior to the procedures was as follows: 379 in patients whose count was
