Newly Published
Perioperative Medicine  |   April 2017
Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group
Author Notes
  • Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan (L.O.L., S.K., T.T.K., M.H., M.E.B.); Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts (B.T.B.); Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon (M.F.A., K.W.H.); Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan (M.M.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina (C.G.G.); and Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (J.B.).
  • Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
  • Beaumont Health, Dearborn, Michigan
  • Beaumont Health, Royal Oak, Michigan
  • Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York
  • Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Langone Medical Center, New York, New York
  • Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
  • St. Joseph Mercy, Ann Arbor, Michigan
  • Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan
  • Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
  • Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee
  • Department of Anesthesiology, University of Utah, Salt Lake City, Utah
  • Department of Anesthesiology, University of Utah, Salt Lake City, Utah
  • Department of Anesthesiology, University of Vermont College of Medicine, Burlington, Vermont
  • Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
  • Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
  • Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
  • Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
  • Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, and
  • Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut.
  • Beaumont Health, Farmington Hills, Michigan
  • Bronson Healthcare, Battle Creek, Michigan
  • Bronson Healthcare, Kalamazoo, Michigan
  • Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
  • Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
  • Department of Anesthesiology, Columbia University Medical Center, New York, New York
  • Holland Hospital, Holland, Michigan
  • Mercy Health, Muskegon, Michigan
  • Department of Anesthesiology, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York
  • St. Joseph Mercy Oakland, Pontiac, Michigan
  • St. Mary Mercy Hospital, Livonia, Michigan
  • Sparrow Health System, Lansing, Michigan
  • Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
  • Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
  • Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
  • Department of Anesthesiology, University of Colorado, Aurora, Colorado
  • Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
  • Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
  • *Multicenter Perioperative Outcomes Group Investigators are listed in appendix 1.
    *Multicenter Perioperative Outcomes Group Investigators are listed in appendix 1.×
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication October 11, 2016. Accepted for publication February 28, 2017.
    Submitted for publication October 11, 2016. Accepted for publication February 28, 2017.×
  • Acknowledgments: The authors gratefully acknowledge the valuable contributions to protocol development and final article review by the Multicenter Perioperative Outcomes Group (MPOG) Investigators and the MPOG publications committee, which is listed in appendix 1. The authors also gratefully acknowledge the valuable contributions to literature review, data collection, and data management by the following individuals: Katherine Boyer, B.S., Danielle Isham, B.S., Jaeho Jeong, M.S., Keerthana Sankar, B.S., and Robert Schoenfeld, B.S., Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan. They also acknowledge Baha M. Sibai, M.D., Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center in Houston, Houston, Texas, for providing clarification of information from a prior publication.
    Acknowledgments: The authors gratefully acknowledge the valuable contributions to protocol development and final article review by the Multicenter Perioperative Outcomes Group (MPOG) Investigators and the MPOG publications committee, which is listed in appendix 1. The authors also gratefully acknowledge the valuable contributions to literature review, data collection, and data management by the following individuals: Katherine Boyer, B.S., Danielle Isham, B.S., Jaeho Jeong, M.S., Keerthana Sankar, B.S., and Robert Schoenfeld, B.S., Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan. They also acknowledge Baha M. Sibai, M.D., Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center in Houston, Houston, Texas, for providing clarification of information from a prior publication.×
  • Research Support: Support for this research was provided under award No. K08HD075831 by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, Bethesda, Maryland (to B.T.B.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Support for underlying electronic health record data collection was provided, in part, by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program for contributing hospitals in the state of Michigan. Although BCBSM and the Multicenter Perioperative Outcomes Group work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.
    Research Support: Support for this research was provided under award No. K08HD075831 by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, Bethesda, Maryland (to B.T.B.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Support for underlying electronic health record data collection was provided, in part, by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program for contributing hospitals in the state of Michigan. Although BCBSM and the Multicenter Perioperative Outcomes Group work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.×
  • Competing Interests: The authors declare no competing interests.
    Competing Interests: The authors declare no competing interests.×
  • Correspondence: Address correspondence to Dr. Lee: Department of Anesthesiology, 1H247 UH, SPC 5048, 1500 East Medical Center Drive, Ann Arbor, MI 48109. lindenl@med.umich.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Hematologic System
Perioperative Medicine   |   April 2017
Risk of Epidural Hematoma after Neuraxial Techniques in Thrombocytopenic Parturients: A Report from the Multicenter Perioperative Outcomes Group
Anesthesiology Newly Published on April 13, 2017. doi:10.1097/ALN.0000000000001630
Anesthesiology Newly Published on April 13, 2017. doi:10.1097/ALN.0000000000001630
Abstract

Background: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population.

Methods: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature.

Results: A total of 573 parturients with a platelet count less than 100,000 mm–3 who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm–3 is 11%, for 50,000 to 69,000 mm–3 is 3%, and for 70,000 to 100,000 mm–3 is 0.2%.

Conclusions: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm–3 remains poorly defined due to limited observations.