|Year : 2007 | Volume
| Issue : 6 | Page : 541-545
Open heart surgery for cyanotic heart disease in a child with immune thrombocytopenic purpura:a case report
Minati Choudhury1, Nirvik Pal2, Usha Kiran3
1 MBBS, MD, Associate Prof, Department of Cardiac Anaesthesia, Department of Cardiac Anaesthesia, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
2 MBBS, MD, Senior Resident, Department of Cardiac Anaesthesia, Department of Cardiac Anaesthesia, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
3 MBBS, MD, Professor & HOD, Department of Cardiac Anaesthesia, Department of Cardiac Anaesthesia, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
|Date of Acceptance||25-Oct-2007|
|Date of Web Publication||20-Mar-2010|
Professor & HOD, Department of CardiacAnaesthesia, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Acute immune thrombocytopenic purpura in children, though a benign self limiting condition, at times complicated with life threatening haemorrhage. In spite of bleeding episode it is inevitable that surgical procedure will be performed on patients with this disease. The anaesthetic implications therefore need to be addressed. Although few reports describing the perioperative management of patients with chronic idiopathic thrombocytopenic purpura are available, literature regarding open heart surgery for cyanotic heart disease is lacking. We describe the management course and raise some anaesthetic considerations for a two year old child with acute immune thrombocytopenic purpura and tetralogy of Fallot's who underwent emergency surgical correction of the cardiac problem under extracorporeal circulation.
Keywords: Acute immune thrombocytopenic purpura, Children, Cardiac surgery
|How to cite this article:|
Choudhury M, Pal N, Kiran U. Open heart surgery for cyanotic heart disease in a child with immune thrombocytopenic purpura:a case report. Indian J Anaesth 2007;51:541-5
|How to cite this URL:|
Choudhury M, Pal N, Kiran U. Open heart surgery for cyanotic heart disease in a child with immune thrombocytopenic purpura:a case report. Indian J Anaesth [serial online] 2007 [cited 2020 Oct 20];51:541-5. Available from: https://www.ijaweb.org/text.asp?2007/51/6/541/61197
| Introduction|| |
Immune thrombocytopenic purpura is primarily a disorder of increased platelet destruction mediated by autoantibodies to platelet membrane antigens.  Therefore surgery in this group of cases carries the risk of major bleeding  .Although there are a number of reports describing the management of the patients undergoing obstetric or general surgical procedures ,, ; literature on perioperative management of idiopathic thrombocytopenic purpura (ITP) patients undergoing open heart surgery are not plenty and there is no report describing acute ITP patient undergoing corrective surgery for cyanotic heart disease.
We report the perioperative management of a child with acute immune thrombocytopenic purpura (ITP) who successfully underwent emergency surgical correction of the underlying cardiac problem.
| Case report|| |
A two-year-old male baby weighing 10 kg, diagnosed case of Down's syndrome; admitted to our hospital with the historyof increasingcyanosis since one month of age, breathlessness for one month, fever and easy bruising for five days. Clinical examination revealed the presence of petechiae around ankle, back of the body and the spleen was enlarged by 2 cm below the costal margin. Laboratory investigation showed abnormally large platelets (3-5µ in diameter) and more than normal variation in shape. There was presence of platelet micro particles. The mean platelet volume was 9.9fl. The total platelet count was 12000 mm 3 .The total leukocyte count and differential count were normal. The results of tests of blood coagulation, including prothrombin time, partial thromboplastin time, and fibrinogenwas normal. The level of fibrinogen degradation products was 7µgm/ml. Bone marrow examination revealed megakaryocytosis, giant megakaryocyte with scanty cytoplasm and relatively few granules than normal platelets. The clinical haematologist confirmed the diagnosis of acute immune thrombocytopenic purpura (ITP). The chest x-ray, electrocardiograph and echocardiography examination identified him as a case of tetralogy of Fallot's. He was treated with oral prednisolone at a dose of 4mg.kg -1 .day -1 for 7 days taper to 21 days. Post treatment his platelet count was 1, 35000/mm 3 .Although an operation had been offered, his parents refused due to financial difficulties. One month later he was brought to the emergency department with the complaint of increased breathlessness and recurrent cyanotic spells. He had two bouts of epistaxis immediately after hospitalization. Physical examination revealed the presence of petechial haemorragic spots on the skin, respiratory rate 40-45/ minute, heart rate 135/minute, regular; and blood pressure 105/85mmHg. On auscultation, his chest was clear; there was presence of systolic murmur at the left upper sternal border. Abdominal examination did not reveal any organomegaly. Treatment was started with oxygen inhalation, fluid therapy, intravenous morphine, propranolol and sodium bicarbonate. Simultaneously other investigations were carried upon. Haematological examination revealed; haemoglobin level of 18.8 gm.dL -1 with normocytic normochromic RBCs; a platelet count of 20,000/mm 3 , abnormally large platelets and presence of platelet microparticles. Auto antibodies to platelet glycoprotein IIb and IIIa were present (detected by antigen capture ELISA test). The total leukocyte count and differential count were normal. He had deficient clot retraction and prolonged bleeding time; which was 24 min (control: 12 min). The prothrombin time, partial thromboplastin time and fibrinogen level were within normal limits; however the fibrin degradation product level was 12 gm.dL -1 . Coomb's test was negative. Specific assay for individual coagulation factor was not done. Electrocardiograph showed the features of right ventricular hypertrophy. X ray chest demonstrated a normal sized boot shaped heart with decreased pulmonary vascular marking. For the bleeding episode he was treated with one unit of single donor apheresis platelet transfusion, one day of immunoglobulin therapy at a dose of 1g.kg -1 and methylprednisolone at a dose of 30 mg.kg1 day -1 for two days. Post treatment his platelet count was 150,000/mm 3 . He underwent diagnostic cardiac catheterization under general anaesthesia which revealed the presence of tetralogy of Fallot's. The child was pre treated with topical EMLA cream applied at the groin one hour prior to local lidocaine infiltration at the start of catheterization. He was given 0.05 mg.kg -1 midazolam intravenously at the onset of the procedure and 1 mg.kg1 intravenous katamine during the procedure. There was presence of moderate sized aortopulmonary collaterals. The coronary anatomy was normal. There was no existence of associated aortic valve regurgitation, patent ductus arteriosus and coarctation of aorta. At the 6 th hour following cardiac catheterization he had four more episodes of hyper cyanotic spell. The partial pressure of oxygen (PaO 2 ) dropped down to as low as 20mmHg during the spell which was 58 mmHg while the child used to be comfortable. As the "tet spell" was non respondent to the medical management, emergency surgical correction was decided upon. The child received 0.2 mg.kg -1 morphine sulphate and 0.02 mg.kg -1 propranonol hydrochloride intravenously before shifting to the operation theatre.After startingelectrocardiograph, pulse oximetry and non invasive blood pressure monitoring anaesthesia induction was started with intravenous ketamine (2 mg.kg -1 ). As soon as the child was asleep oxygen mask was placed over his face and rocuronium bromide 0.06 mg.kg -1 was given. Number 5.0 size uncuffed endotracheal tube was passed orally with the help of a stylet to secure the airway. The child was mechanically ventilated with a mixture of oxygen and air in a mixture of 50:50. Anaesthesia was maintained with fentanyl, midazolam and pancuronium bromide. Optimal care was taken to avoid injury during laryngoscopy, intubation and temperature probe insertion. Continuous pulse oximetry, nasopharyngeal temperature, invasive blood pressure, end- tidal carbon dioxide, inspired concentration of oxygen( FiO 2 ), central venous pressure , bispectral index and urine output were monitored throughout the course of anaesthesia and surgery. The haemoglobin level and platelet count as sent before shifting the patient before surgery showed a value of 19gm.dl -1 and 1, 20, 000/mm 3 respectively.The post intubation blood gas value revealed a PaO 2 of 59mmHg, PaCO 2 35mmHg. There was no feature of metabolic acidosis. During the prebypass period care was taken to maintain the optimal haemodynamics, oxygenation and intraoperative factor which could precipitate the cyanotic spell. He received methylprednisolone 30mg.kg -1 and aprotinin 100,000 KI Units.kg -1 .hr -1 during the intraoperative period. The base line activated clotting time (ACT) was 136 seconds and came to 265 seconds after systemic heparinization with 300 units.kg -1 body weight of heparin .After addition of 200 units.kg -1 of heparin theACT raised to 325 seconds. Keeping the possibility of heparin resistance secondary to antithrombin III (AT III) deficiency blood sample was sent for AT III and platelet factor 4 (PF 4 ) estimation and one unit fresh frozen plasma was transfused which raised the ACT to 425 seconds and cardiopulmonary bypass was initiated. The cardiopulmonary bypass (CPB) circuit was primed with 2 units of blood, 500 ml of Ringer lactate, 50 ml of 20% mannitol, and 50 mg of heparin and 20 ml of sodium bicarbonate. Heart was arrested with antegrade hyperkalemic cold blood cardioplegia. The patient was cooled to a venous return temperature of 28 0 C while on bypass and was rewarmed to a rectal temperature of 36 0 C before separation from CPB. Two units of fresh frozen plasma and 10 ml of 20% albumin were added to the pump during CPB to maintain the prime volume. The haematocrit was maintained above 30% during the course of CPB.Additional 100 units.kg1 of heparin was added in the pump and the ACT remained between 400-565 seconds through out. Separation from cardiopulmonary bypass was accomplished with dopamine 5µg.kg -1 .min -1 and sodium nitroprusside 0.5µg.kg -1 min -1 . The haemoglobin level remained between 10 to 13 gm.dL -1 during CPB and 14 gm.dL -1 in the immediate post CPB period. Protamine neutralization of heparin resulted an ACT level of 131 seconds. The total duration of surgery, CPB time and aortic cross clamp time were 185 min 112 min and 68 min respectively. One unit of single donor apheresis platelet (SDP) was transfused as the platelet count dropped as low as 24,000 mm 3 during cardiopulmonary by pass. Haemostasis after CPB required the same time as the usual cases of similar group. No residual solution from CPB circuit was transfused to the patient. At the second postoperative hour his bleeding time, prothrombin time and activated partial thromboplastin time were found to be normal. He was extubated on the sixth post operative hour. There was no significant bleeding after 24 hour of surgery in spite a platelet level of 42,000/mm 3 . The bleeding time was 25 min at the same time. Hence to prevent a sudden onset of bleeding episode the authors had to give platelet transfusion (one unit SDP) to maintain a platelet count more than 125,000/mm 3 . On the 3rd postoperative day he developed sudden onset of features of cardiac tamponade which was confirmed by transoesophageal echocardiography. The tamponade was released under general anaesthesia with midazolam 0.05 mg.kg -1 and fentanyl 2µg.kg -1 along with oxygen and air in the ratio of 50:50. It was found to be caused by the migration of pacing wire into one of the coronary veins.Approximately 200 ml of collected blood was taken out. He received one unit of fresh blood transfusion as the haemoglobin level dropped down to as low as 10gm.dL -1 . He was extubated 3 hours later. From the 4th post operative day onwards platelet count remained stable at 135,000/mm 3 . Chest tubes were removed on the 5th post operative day with a cumulative drainage of 225 ml which was little higher than the similar cases in our setup. During the whole postoperative course he received two unit of fresh blood, one unit of fresh frozen plasma and one unit of SDP .He was discharged on the 8th post operative day. The pre CPB blood sample revealed no abnormality in PF4 where as the AT III level was found to be 60% and the result was included in the discharge summary for the future precaution.
| Discussion|| |
The American Society of Hematology Panel defined idiopathic thrombocytopenic purpura as "isolated thrombocytopenia with no clinically apparent associated conditions or other causes of thrombocytopenia, eg. systemic lupus erythematosus and stressed that the diagnosis of idiopathic thrombocytopenic purpura is primarily one of the exclusion.  Acute immune thrombocytopenic purpura in childhood though a self limiting disorder , at times complicated by serious bleeding.  The risk of life threatening haemorrhage is highest within the first few weeks so affected children should avoid trauma and restrict physical activity as much as possible.  Current treatment strategies for acute ITP include oral or intravenous corticosteroids, anti-Rh(D), intravenous immunoglobin and observation alone.  Although there is no published data on the efficacy of different treatments for the management of children with urgent life threatening bleeding, there is universal agreement that such children require aggressive therapy. Appropriate interventions in this group include high dose intravenous corticosteroid,intravenousimmunoglobulin andplatelet transfusion. 
Platelet consumption and dysfunction is common sequelae of CPB technique among a whole array of potential complications. Resultant bleedingdiathesis compounded by an accompanying cascade of coagulopathy can become a major perioperative concern, culminating in significant transfusion and reexploration .  On the other hand; immune thrombocytopenic purpura can itself contribute to a very low platelet count leading to feared complications like intra cranial haemorrhage  . The association of cyanotic heart disease, deranged platelet function, coagulation factor dysfunction and increased incidence of excessive post operative bleeding is well known.  Thus it is possible for the platelet count to fall to excessively low levels during and after cardiopulmonary bypass in such patients suffering from ITP leading to a complicated course. Therefore intensive perioperative management should be planned for patients with ITP in an attempt to avoid the depletion of platelets as well as the coagulation factors.
In patient suffering from ITP preoperative immunosuppressive therapy and corticosteroid treatment seem to be unsuitable due to high incidence of post operative infectious complications. High dose gamma globulin therapy was found to be more appropriate in such cases.  However in spite of pre-treatment with high dose corticosteroid and immunoglobulin our patient did not show any evidence of infection during the post operative period.
We support Sato, Inoue and colleagues who suggested that ITP cases may possibly undergo cardiac surgery under cardiopulmonary bypass without a markedly enhanced risk for bleeding complications, despite a more than usual transfusion requirement and significantly low platelet count perioperatively. , As the haemorrhagic risk increase with haemodilution the haematocrit level was maintained more than 30% during cardiopulmonary bypass which was the usual period of haemodilution.  Jobes and colleagues recommended fresh whole blood as part of the priming to improve haemostasis after cardiopulmonary bypass.  It is also an established fact that anaemia is lessened with fresh whole blood, whereas excessive bleeding and transfusion are minimized. , The above truths were achieved by blood priming and addition of albumin and fresh frozen plasma rather than crystalloid to maintain the pump volume during cardiopulmonary bypass. Hypothermia, another contributory factor for bleeding especially in cardiac surgical procedure has been associated with dysfunction of enzymatic function, reduced platelet activity and /or altered fibrinolysis.  To reduce the hypothermia related bleeding episode temperature was maintained at 36-37 0 C through out the postoperative course with the help of warming blanket.
The role of prophylactic platelet transfusion has been described in severely thrombocytopenic patients without evidence of bleeding but no randomized data prove the safety or efficacy of this approach.  The issue regarding the role of prophylactic platelet transfusion before surgery in thrombocytopenic surgical patients is also controversial.  Lemmer advocated prophylactic transfusion of one platelet dose (either one apheresis platelet or six random donor unit) after administration of protamine in case of qualitative platelet defect caused by abciximab.Additional platelets and other blood products should be transfused as indicated by usual clinical and laboratory measurements  . Therapeutic platelet transfusion have been documented to control bleeding , and the mortality rates are not increased when comparing patients receiving therapeutic to that seen in patients receiving prophylactic platelet transfusion.  Threshold platelet counts for perioperative transfusion have not yet been clearly defined and should be determined by the existence of haemorrhagic factors. The standard threshold for haemorrhagic risk for surgery is 50,000/mm 3 including cardiac surgery with cardiopulmonary bypass.  Our patient needed platelet transfusion after hospitalization because of severity of the disease condition and emergency of surgical management. The child required platelet transfusion both intra and postoperatively as the platelet count dropped down below the safety level. Multimodality approach was applied to him because the severe acute presentation of ITP. We chose single donor apheresis platelet transfusion to reduce donor exposure and risk for virus transmission or HLA alloimmunization and of its cost effectiveness. , .
Haemorrhagic diathesis due to ITP may cause considerable risk of bleeding and aspiration into the lungs. Traumaduringmaskventilationandlaryngoscopyandeven trivial trauma by the adhesive electrodes and adhesive tapes used for the fixation of the endotracheal tube may precipitate bleedingin patients with ITP. Possibility of difficult intubation in our case due to the presence of large tongue and high arched palate was a potential risk factor for additional trauma and bleeding during laryngoscopy andintubation.This wasavoidedbysmooth andatraumatic intubation with an appropriate size of endotracheal tube, expert help and good muscle relaxation.
Our report showed that emergency cardiopulmonary bypass and cardiac surgery can be safely performed in cyanotic patient with acute ITP combined with AT III deficiency. Preoperative platelet transfusion, combined immunoglobulin and corticosteroid treatment may be helpful if the presentation of ITP is severe and emergency surgery is required. Strict vigilance and optimum care should be taken during cardiopulmonary bypass and there after to avoid bleeding due to dilutional anaemia and low platelet count. Use of single donor apheresis platelet transfusion can minimize the volume over load in a small child without causing any excessive bleeding, coagulopathy and thereby decreasing the additional demand from the blood bank.
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