PB1033 - Delphi consensus recommendations for neuraxial anesthesia in adults with platelet disorders and coagulation defects

Tuesday, June 27, 2023

18:30 – 19:30 ET

Room: Exhibition

Presenting Author(s)

Wynn Peterson, MD (she/her/hers)

Resident Physician
Division of Hematology, Queen's University
Kingston, Ontario, Canada

Co-Author(s)

RM

Rachel Martin

Assistant Professor
Unity Health Toronto, University of Toronto
Toronto, Ontario, Canada
Donald Arnold, MD MSc (he/him/his)

Professor
McMaster University, Department of Medicine
HAMILTON, Ontario, Canada
BC

Brendon Carvalho

Division Chief of Obstetric Anesthesiology and Maternal Health
Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine
Palo Alto, California, United States
Adam Cuker, MD, MS (he/him/his)

Associate Professor
Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
Philadelphia, Pennsylvania, United States
Drew Provan, MD

Emeritus Reader in Autoimmune Haematology
Barts and the London School of Medicine and Dentistry, Queen Mary University of London
London, England, United Kingdom
NR

Natalia Rydz

Clinical Associate Professor
Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, AB, Canada
Calgary, Alberta, Canada
ES

Eliane Shore

Associate Professor
Obstetrics & Gynecology, St. Michael's Hospital, University of Toronto
Toronto, Ontario, Canada
David J. J. Kuter, MD, DPhil

Director of Clinical Hematology
Hematology Division, Massachusetts General Hospital, Harvard Medical School
Boston, Massachusetts, United States
Peter Kouides, MD

Physician - Hematology/Oncology
Mary M. Gooley Hemophilia Centre, Rochester, NY, USA
Rochester, New York, United States
Michelle Lavin, MB, PhD (she/her/hers)

Consultant Haematologist
National Coagulation Centre, St. James Hospital and Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Physicians and Surgeons in Ireland (RCSI)
Dublin, Dublin, Ireland
Paula James, MD

Professor
Department of Medicine, Queen's University, Kingston, ON, Canada
Kingston, Ontario, Canada
DE

Dale Engen

Assistant Professor
Department of Anesthesiology and Perioperative Medicine, Queen’s University
Kingston, Ontario, Canada
Michelle Sholzberg, MDCM, FRCPC, MSc., MDCM, FRCPC, MSc

Head, Division of Hematology-Oncology
Departments of Medicine, and Laboratory Medicine and Pathobiology, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
Toronto, Ontario, Canada

Background: Spinal and epidural hematomas are serious complications of neuraxial anesthesia procedures. Patients with platelet disorders and coagulation defects are at higher risk of bleeding complications; however, there is a lack of evidence to inform safe use of neuraxial anesthesia in this population.

Aims: To develop consensus recommendations for clinical use of neuraxial anesthesia in patients with platelet disorders and coagulation defects.

Methods: A three-round electronic modified Delphi consensus was conducted using a set of initial statements developed by a steering committee of 14 experts in hemostasis and anesthesiology. Statements included hypothetical scenarios of obstetrical and non-obstetrical patients both with and without a marked personal history of bleeding. Panelists were recruited via snowball sampling. In the first round, panelists rated their level of agreement with hemostatic laboratory threshold options for each statement on a five-point Likert scale. Statements were rephrased based on panelist feedback and the minimum hemostasis laboratory threshold achieving agreement for each statement was selected to proceed. Responses from the second round were analyzed for consensus, defined as ≥70% agreement (“agree” or “strongly agree” on the Likert scale). A third round was conducted in the same manner. Informed consent was obtained from each panelist prior to participation. The study was approved by Research Ethics and endorsed by the ISTH SSC Subcommittee on von Willebrand Factor.

Results: Forty-five international panelists (23 hematologists, 22 anesthesiologists) participated. Response rate for all three rounds was 67%. Statements encompassed a variety of inherited and acquired platelet disorders and coagulation defects (Table 1), and consensus was achieved for all 34 statements. General statements are presented in Table 2.

Conclusion(s): Using Delphi methodology, we identified 34 consensus-based recommendations for use of neuraxial anesthesia in patients with 11 platelet disorders and coagulation defects. These recommendations may supplement individualized decision-making in this challenging clinical setting.