Variation in Perioperative Management Practices and Bleeding Risk in Pediatric Immune Thrombocytopenia (ITP)

Introduction: Pediatric patients with immune thrombocytopenia (ITP) undergoing surgical procedures may be at an increased risk of bleeding, thus providers may pursue additional perioperative ITP-directed treatments. No guidelines exist in the United States for platelet (plt) goals or suggested management practices for pediatric patients with ITP undergoing surgery, thus providers lack guidance for perioperative management of ITP. We aimed to study pediatric patients with ITP undergoing surgeries over a 10-year period to characterize perioperative ITP management, report adverse outcomes, and identify factors associated with increased perioperative bleeding risk.

Methods: We completed an IRB-approved retrospective review of patients (pts) aged 0-24 years with ITP at a tertiary referral children's hospital who underwent surgical procedures between 2014-2024. Pts with non-chronic ITP that resolved prior to surgery and pts not actively followed by Hematology were excluded. Clinical characteristics, ITP-directed treatments, and outcomes were summarized based on surgery type. Groupwise comparisons were made between pts with and without bleeding events using Mann-Whitney U or Fisher's exact testing.

Results: A total of 43 surgeries in 34 pts met inclusion criteria. Dental extraction (n=12) and appendectomy (n=4) were the most common surgical procedures. Twelve pts, all with plt counts of <150,000/µL at the time that surgery was recommended, received additional perioperative ITP treatment(s) in addition to their baseline ITP treatment. The majority (11/12, 92%) of patients prescribed these treatments had platelet counts <100,000/µL at the time that surgery was recommended. In patients with platelet counts >100,000/µL (n=20), only 1 patient was prescribed additional perioperative ITP-directed treatment. Prescribing practices varied, and included antifibrinolytics (n=4), oral steroids (n=2), intravenous immunoglobulin (IVIG) (n=2), and other (n=4). Plt count at the time of surgery was significantly related to bleeding risk and was significantly lower in surgeries with bleeding events (n=6) compared to without bleeding events (n=28); p=0.01. Six bleeding events were reported in 5 pts, including (1) Oral bleeding secondary to a root canal requiring pressure and topical treatment with a pre-operative (pre-op) plt count of 66,000/µL and no pre-planned perioperative treatment (2) Oral bleeding secondary to tooth extraction requiring pressure and topical treatment with a pre-op plt count of 69,000/µL and planned perioperative antifibrinolytic treatment (3) Oral bleeding secondary to tooth extraction requiring subsequent hematoma drainage with a pre-op plt count of 1,000/µL and no planned perioperative treatment (4) Rectal bleeding secondary to gastrointestinal endoscopy which resolved spontaneously with a pre-op plt count of 122,000/µL and no planned perioperative treatment (5) Intracranial hemorrhage secondary to evacuation of a temporal hematoma leading to brain death with a pre-op platelet count of 24,000/µL and 5 perioperative treatments (IV steroids, IVIG, platelet transfusions, antifibrinolytic, and recombinant factor VIIa) and (6) Uncontrolled bleeding secondary to orchiopexy leading to surgery cessation with an undetectable pre-op plt count and no pre-planned perioperative treatment. Consultation with Hematology, provision of ITP treatment(s) perioperatively, and platelet response to prescribed ITP treatment were not significantly related to bleeding risk. Nine procedures were excluded from the bleeding analysis due to lack of reported bleeding outcomes and plt count data. No medication side-effects or readmissions were reported within 4 weeks of surgery.

Conclusions: In this study, we identified 43 surgeries and 6 bleeding events in pediatric ITP pts. We observed heterogeneous management practices for pts across different plt count ranges and surgeries. Pts with perioperative bleeding events had significantly lower plt counts at the time of surgery, and most of those pts received no perioperative treatments. Guidance on standard practice recommendations for management of patients with ITP to mitigate bleeding events may be helpful. In future work, we plan to evaluate a larger pt population through a multi-institutional retrospective study with the ultimate goal of creating recommendations for perioperative management of ITP.

No relevant conflicts of interest to declare.