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Acute onset severe thrombocytopenia after brain tumor resection under total intravenous anesthesia

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Euroanaesthesia 2017

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Title: Acute onset severe thrombocytopenia after brain tumor resection under total intravenous anesthesia Author(s): Matas M., Sekulić A., Miklić-Bublić M. Institute(s): University Hospital Zagreb, Dept of Anaesthesiology & Intensive Care, Zagreb, Croatia Text: Background: Drug induced thrombocytopenia can be easily overlooked (1). Postoperative drop in platelet count, after brain tumor surgery, can cause hematoma formation (2) and significant mortality. Case report: ASA II 70-year neurosurgical patient, without focal signs, was scheduled for left frontal lobe tumor resection. Preoperative platelet count was 180x109. Laboratory tests were normal. Two prior surgeries were uneventful. Infection prophylaxis included cefazoline 2 g iv. Premedication consisted of midazolam 5 mg im. Anesthesia with fentanyl, propofol and rocuronium was induced and maintained with infusions of propofol and fentanyl. Haemoglobin levels during surgery were stable. Anesthesia went uneventful. After transfer to ICU, the first postoperative finding was thrombocytopenia of 4 x109 platelets. Twenty minutes later platelet count was 8 x 109. Both the citrate and EDTA tests showed similar low platelet count. Five hours after the admission to the ICU new left hemiplegia was the reason for an emergency MSCT. After transfusion of 8 units of platelets in site hematoma was evacuated. The second anesthesia was performed with midazolam and ketamine. The patient fully recovered with no new neurologic deficits. Platelet count remained normal. Heparin induced thrombocytopenia antibodies were not found. Specific drug antithrombocyte antibodies test wasn´t available. Discussion: Possible causes of acute postoperative thrombocytopenia in our patient were: dilutional effect of fluid rescucitation, unrecognized platelet pathology, nonimmune and immune thrombocytopenia not related to medications, heparin induced thrombocytopenia, pseudothrombocytopenia and other drug induced thrombocytopenias. Heparin induced thrombocytopenia and pseudothrombocytopenia were excluded. The diagnosis of drug induced thrombocytopenia was the most probable. For the second surgery we decided to avoid cefazoline, propofol, fentanyl and rocuronium. The platelet count remained stable during and after the second surgery. References: 1. Aster RH, Bougie DW Drug-Induced Immune Thrombocytopenia N Engl J Med 2007; 357:580-587. 2. Chan KH, Mann KS, Chan TK. The significance of thrombocytopenia in the development of postoperative intracranial hematoma. J Neurosurg. 1989;71(1):38-41 Learning points: Platelet count after brain tumor surgery in total intravenous anesthesia should be monitored in short intervals during first hours.

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