Neuraxial analgesia in a patient with factor XII deficiency
Bogan J, Saraswat A, Alsaden MR, Guruswamy J. Neuraxial analgesia in a patient with factor XII deficiency. Regional Anesthesia and Pain Medicine 2017; 42(6).
Regional Anesthesia and Pain Medicine
Introduction Defects in the coagulation pathway involving Factor XII (Hageman factor) causes laboratory abnormalities without clinical bleeding. Studies show that individuals who are deficient in Factor XII can have normal hemostasis and are able to undergo major surgeries without plasma replacement therapy despite dramatic PTT elevation. The ability to maintain a normal coagulation cascade may be accredited to the direct activation of Factor IX by the tissue factor and VIIa complex, which bypasses the defective step and thus compensates for the deficiency of Factor XII. This report presents the case of a 74 year old male with Factor XII deficiency who underwent extensive abdominal surgery with neuraxial analgesia for postoperative pain control without hemostasis sequelae. No blood products were given during the case. Written informed consent from patient was obtained before case report production and it is available upon request. Results/Case report It was noted preoperatively that the patient had lab values showing PTT >200 and factor XII <2%. No history of bleeding was documented. Series of tests showed partial correction of PTT on mixing study and possible minor and nonspecific inhibitors to factors of intrinsic pathway. In view of normal activities of factors VIII, IX and XI patient was deemed not at risk of bleeding. Given the fact that the patient was deemed to not have a bleeding diathesis and there is substantial evidence in the literature stating that despite the in vitro PTT abnormality, there is no clinically significant coagulopathy in patients with factor XII deficiency, decision was made to proceed with epidural placement for post-operative pain management. Coagulation labs were checked prior to the procedure. INR 1.34, PT 16.4, PTT 66, platelets 173. Epidural was placed by regional anesthesia staff using standard placement method. There was no excessive bleeding noted other than what was expected from insertion and removal of the Tuohy needle. Patient tolerated the procedure without any complications. Epidural remained in place for a duration of 5 days without issues prior to removal. Coagulation panel was checked prior to removal. Catheter was removed from the epidural space uneventfully without bleeding and neurological sequelae. Epidural site remained clean, dry and intact without hematoma and bleeding on 24-hour follow up after catheter removal. Discussion Surprisingly, factor XII deficiency does not lead to abnormal bleeding, even with major surgical procedures. The lack of bleeding manifestations is not fully understood. Factor XII deficiency is usually discovered incidentally through a routine coagulation testing done prior to surgery. The main concern related to factor XII deficiency is the unnecessary testing, delay in health care and worry of surgical interventions that may be prompted by the abnormal laboratory result. To our knowledge, this is the first case report in literature documenting a patient with factor XII deficiency receiving neuraxial block. There have been case reports of patients with factor XII deficiency undergoing obstetric procedures, major surgeries and even cardiac surgery with cardiopulmonary bypass without major hemostasis issues. Few case reports suggest use of FFP to correct the lab abnormality, but accepted the futility of doing so.