Evaluation and management of coagulation disorders in elective surgical patients

Abstract

This is a review of coagulation disorders in elective surgical patients. The study represents both a personal experience in unusual bleeding and clotting disturbances and, in addition, a 15‐year review of unique problems evaluated by the Coagulation Department of a local general hospital. Of this group of cases, 17 were selected to illustrate the purpose of this report. Potential “bleeders” due to coagulation defects may be missed preoperatively both by history and by commonly accepted screening tests. The incidence of this situation is fortunately rare, but unfortunately this dulls the likelihood of early diagnosis with the initiation of specific treatment measures. The limitations of preoperative screening tests were apparent and should not be considered a fail‐safe detector of coagulation disorders. Qualitative and quantitative factor assays are the cornerstone for accurate diagnosis and a guide for specific replacement therapy. Although most surgeons will never have an in‐depth knowledge of hematology, the importance of having some fundamental awareness is apparent. This study encourages surgeons not to take the hemostatic mechanism for granted, and to see the need for understanding hematologic diagnosis and treatment.

Preoperative Hemostatic Assessment of the Adenotonsillectomy Patient

“…The literature is replete with reports of intraoperative and postoperative hemorrhage resulting from unrec ognized coagulopathies. 4,l3l5,l ' J " 23 A surprising number of such reports arise from otolaryngologic procedures, largely adenotonsillectomies. 4,13 • 1419 " 21, 23 Fuller's review of a 15-year experience of a coagu lation department at a general hospital illustrates this predilection.…”

“…4,13 • 1419 " 21, 23 Fuller's review of a 15-year experience of a coagu lation department at a general hospital illustrates this predilection. 4 Of the 63 special hématologie case rec ords available for review, 15 were from otolaryngologic surgical admissions-14 of these were adenotonsillectomy patients. Eight of the 14 adenotonsillectomy pa tients experienced intraoperative or postoperative hem orrhage caused by hemostatic defects that were not rec ognized preoperatively.…”

“…4,l3l5,l ' J " 23 A surprising number of such reports arise from otolaryngologic procedures, largely adenotonsillectomies. 4,13 • 1419 " 21, 23 Fuller's review of a 15-year experience of a coagu lation department at a general hospital illustrates this predilection. 4 Of the 63 special hématologie case rec ords available for review, 15 were from otolaryngologic surgical admissions-14 of these were adenotonsillectomy patients.…”

“…We agree with the recommendation by Tami et al 1 that, despite a negative preoperative history, a per sistently abnormal preoperative clotting studyregardless of how minor-deserves a complete and formal hématologie evaluation before tonsillectomy. Of the 11 patients who ultimately underwent adenotonsillectomy in Fuller's 4 series, four patients experienced perioperative hemorrhage and were noted to have had abnormal preoperative laboratory PT/PTT or bleeding time tests that had not been further investigated. Several studies have illustrated the pattern for some practitio ners to ignore the results of abnormal laboratory screen ing tests.…”

“…Intraoperative or postoperative hemorrhage resulting from an unrecognized hemostatic defect may be partic ularly distressing to the otolaryngologist. 4 In cases in which a significant hemostatic disorder exists, the op erator discovers that no degree of attention to surgical hemostatic technique will prevent or sufficiently control bleeding. 3 • 4 Preoperative identification of occult he mostatic defects, coupled with perioperative manage ment directed at correcting the effects of these defects, should reduce the incidence of this distressful compli cation.…”