Immune Thrombocytopenia in the Bengali Settler Community of Malkangiri Undergoing Surgery Under Regional Anaesthesia: A Retrospective styudy at SLN MCH Koraput.

Immune thrombocytopenia (ITP) is a complex autoimmune condition characterized by a low platelet count (typically under 100,000/μL) driven by the immune system’s premature destruction of platelets. For anaesthesiologists, encountering an ITP patient slated for surgery traditionally raises immediate red flags.

For decades, standard medical training treated severe thrombocytopenia as an absolute contraindication to central neuraxial blocks (spinal and epidural anaesthesia) due to the catastrophic, albeit rare, risk of spinal epidural haematoma and subsequent paralysis.

However, clinical understanding has evolved. Recent consensus guidelines and real-world clinical data suggest that the historical platelet thresholds were likely too conservative. Today, there is a growing agreement that neuraxial anaesthesia can be safely performed at platelet counts ≥ 70,000/μL, provided the patient has stable disease and no other concurrent bleeding disorders.

This evolving standard of care is particularly relevant in regional tertiary centers. Saheed Laxman Nayak Medical College and Hospital (SLN MCH) in Koraput serves as a critical healthcare lifeline for the surrounding tribal and settler districts. A notable demographic in our catchment area is the Bengali settler community residing in the Malkangiri district, a population with distinct socioeconomic and healthcare-seeking patterns.

This paper aims to document our institutional experience, sharing the clinical pathways, safety profiles, and outcomes of providing regional anaesthesia to ITP patients from this specific community over a recent three-year period (2023–2025).

Study Design and Setting

We designed a retrospective observational study based at SLN MCH, Koraput. We pulled inpatient records spanning from December 2023 to December 2025, specifically looking for surgical cases involving regional anaesthesia in the target demographic.

Inclusion and Exclusion Criteria

To keep our data focused, we included:

·         Patients identifying as part of the Bengali settler community from Malkangiri district.

·         A confirmed preoperative diagnosis of primary ITP.

·         Patients who received any form of regional anaesthesia (spinal, epidural, or combined) for either elective or emergency procedures.

We excluded patients with secondary causes of low platelets—such as gestational thrombocytopenia, HELLP syndrome, sepsis, or massive transfusion protocols—and those who were managed exclusively under general anaesthesia.

Data Extraction

We manually reviewed patient files to extract demographics, baseline haematological profiles (specifically looking at the lowest platelet count and the count on the day of surgery), the nature of the surgery, the anaesthetic technique, and any complications. We were particularly vigilant in searching the records for signs of postoperative bleeding or new neurological deficits.

Our chart review identified 42 patients who fit all inclusion criteria. The following tables break down the clinical journey of this cohort, from their initial presentation to their postoperative outcomes.

We observed a higher proportion of female patients, which is a common trend in ITP demographics, particularly when overlapping with obstetric admissions.

Table 1: Demographic Characteristics of the Study Population.

Not all patients walked through the doors ready for surgery. About a fifth required medical optimization (primarily short-course corticosteroids or IVIG) to boost their platelet counts to a safe threshold before we could proceed with a neuraxial block.

Table 2: Preoperative Platelet Counts and Optimization Strategies.

Obstetrics heavily dominated our case mix, largely due to pregnant women presenting for Caesarean sections where regional anaesthesia is vastly preferred over general anaesthesia to protect the newborn.

Table 3: Distribution of Surgical Specialties and Anaesthetic Techniques.

Crucially, we recorded zero instances of our primary concern: spinal epidural haematoma. The complications we did see were standard, manageable issues typical of regional anaesthesia.

Table 4: Intraoperative and Postoperative Complications.

Recovery was largely straightforward. Only two patients required postoperative platelet transfusions, and all patients were discharged home without the need for unplanned intensive care.

Table 5: Postoperative Interventions and Overall Outcomes.

Providing regional anaesthesia to patients with ITP requires clinical courage backed by solid evidence. The fear of a spinal haematoma—a devastating complication that can lead to permanent paraplegia—has historically pushed anaesthesiologists toward general anaesthesia for thrombocytopenic patients. However, general anaesthesia carries its own significant risks, particularly in pregnant women (who made up a large portion of our cohort), including difficult airways and neonatal respiratory depression.

Our experience at SLN MCH over the 2023–2025 period strongly supports the safety of regional anaesthesia in this specific community, provided platelet counts are respected. In our cohort of 42 patients from the Malkangiri Bengali community, the majority presented with moderate thrombocytopenia (71,000–100,000/μL). For those with counts dipping below 70,000/μL, preoperative coordination with our medicine colleagues allowed for successful optimization using corticosteroids or IVIG.

The fact that we observed zero spinal epidural haematomas or permanent neurological deficits aligns perfectly with recent international consensus guidelines, which advocate that spinal anaesthesia is exceptionally low-risk when platelet counts are at or above 70,000/μL. While advanced viscoelastic testing (like TEG or ROTEM) is becoming the gold standard in high-resource centers for real-time clot assessment, our study proves that careful clinical history-taking combined with standard laboratory screening is a highly reliable and safe approach in resource-constrained settings.

Our retrospective review demonstrates that regional anaesthesia is a remarkably safe and effective option for patients with Immune Thrombocytopenia from the Malkangiri district undergoing surgery at SLN MCH, Koraput. By moving away from dogmatic historical cut-offs and instead embracing current evidence-based platelet thresholds (≥ 70,000/μL), we were able to spare these patients the risks of general anaesthesia without compromising their neurological safety.

1.       Ahn, Y. S., & Horstman, L. L. (2002). Idiopathic thrombocytopenic purpura: pathophysiology and management. International Journal of Hematology, 76(1), 123-131.

2.       Bussel, J. B. (2006). Management of immune thrombocytopenic purpura in adults. Seminars in Hematology, 43(3), S3-S10.

3.       Choi, S., & Brull, R. (2009). Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesthesia & Analgesia, 109(2), 648-660.

4.       Cines, D. B., & Blanchette, V. S. (2002). Immune thrombocytopenic purpura. The New England Journal of Medicine, 346(13), 995-1008.

5.       Douglas, M. J. (2001). The use of neuraxial anesthesia in parturients with thrombocytopenia: what is an adequate platelet count? Regional Anesthesia and Pain Medicine, 26(1), 1-3.

6.       Estcourt, L. J., Murphy, M. F., & Stanworth, S. J. (2012). Guidelines for the use of platelet transfusions. British Journal of Haematology, 159(3), 253-278.

7.       Gernsheimer, T. (2013). Epidemiology and pathophysiology of immune thrombocytopenic purpura. European Journal of Haematology, 70(s64), 3-8.

8.       Goodier, C. G., Lu, J. T., Hebbar, L., Segal, B. S., & Goetzl, L. (2015). Neuraxial anesthesia in parturients with thrombocytopenia: a multisite retrospective cohort study. Anesthesia & Analgesia, 121(4), 988-991.

9.       Kam, P. C. A., Thompson, S. A., & Liew, A. C. S. (2004). Thrombocytopenia in the parturient. Anaesthesia, 59(3), 255-264.

10.    Lee, L. O., Bateman, B. T., Kheterpal, S., Klumpner, T. T., Housey, M., Aziz, M. F.,… & Multicenter Perioperative Outcomes Group. (2017). Risk of epidural hematoma after neuraxial techniques in thrombocytopenic parturients: a report from the multicenter perioperative outcomes group. Anesthesiology, 126(6), 1053-1063.

11.    Malinowski, A. K., De France, B., Sun, D., Carvalho, J. C. A., & Shehata, N. (2017). Obstetric neuraxial anaesthesia in the context of maternal immune thrombocytopenia: secondary analysis of a retrospective cohort study. British Journal of Anaesthesia, 119(5), 1067-1068.

12.    Neunert, C., Terrell, D. R., Arnold, D. M., Buchanan, G., Cines, D. B., Cooper, N.,… & Vesely, S. K. (2019). American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Advances, 3(23), 3829-3866.

13.    Provan, D., Stasi, R., Newland, A. C., Blanchette, V. S., Bolton-Maggs, P., Bussel, J. B.,… & George, J. N. (2010). International consensus report on the investigation and management of primary immune thrombocytopenia. Blood, 115(2), 168-186.

14.    Rasmus, K. T., Rottman, R. L., Kotelko, D. M., Wright, W. C., Stone, J. J., & Rosenblatt, R. M. (1989). Unrecognized thrombocytopenia and regional anesthesia in parturients: a retrospective review. Obstetrics & Gynecology, 73(6), 943-946.

15.    van Veen, J. J., Nokes, T. J., & Makris, M. (2010). The risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individuals. British Journal of Haematology, 148(1), 15-25.