Anaesthesia for urgent splenectomy in acute idiopathic thrombocytopenic purpura

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A previously fit and well middle-aged woman with a diagnosis of acute idiopathic thrombocytopenic purpura, failed to respond to standard medical treatment with oral steroids and intravenous immunoglobulin. The decision was taken to proceed to open splenectomy in the presence of severe refractory thrombocytopenia [1]. Pre-operative assessment revealed an enlarged, swollen tongue with small surface haematomas and extensive blood blisters on the buccal mucosa. There were no signs of airway obstruction although she complained of a hoarse voice and had experienced a few episodes of haemoptysis. There were no symptoms of gastro-oesophageal reflux. A full blood count showed a platelet count of 1 × 109.l−1 on the day of operation.

There was concern that laryngoscopy and tracheal intubation may lead to damage of mucosal surfaces, particularly around the laryngeal inlet and trachea, with subsequent haemorrhage [2, 3]. We were also concerned that any coughing induced by the tracheal tube could cause an intracranial bleed [4]. For these reasons, a Classic Laryngeal Mask Airway (Intavent, Maidenhead, Berkshire, UK) was used. One pool of platelets was administered in the anaesthetic room. After induction of anaesthesia, a size 3 Classic Laryngeal Mask Airway was gently passed without difficulty using the standard insertion technique. Positive pressure ventilation was continued during the procedure.

After the splenic artery had been clamped, a further two pools of platelets were given and the operation proceeded uneventfully. The laryngeal mask airway was removed with the patient spontaneously breathing and fully awake. The patient was monitored on the high dependency unit for 5 days before making a full recovery.

A literature search found only one report on anaesthetic management in a similar case with an extremely low platelet count. Here, the authors intubated the trachea without any subsequent complications [5]. In our case, the risks of tracheal trauma and intracranial haemorrhage associated with a tracheal tube were felt to outweigh the risk of gastric aspiration associated with the use of a laryngeal mask airway. We acknowledge that a device such as the Proseal Laryngeal Mask Airway (Intavent) may have been even more suitable, although its insertion may not have been as atraumatic as that with the Classic Laryngeal Mask Airway.

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