Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures

Abstract

SummaryUnselected coagulation testing is widely practiced in the process of assessing bleeding risk prior to surgery. This may delay surgery inappropriately and cause unnecessary concern in patients who are found to have 'abnormal' tests. In addition it is associated with a significant cost. This systematic review was performed to determine whether patient bleeding history and unselected coagulation testing predict abnormal perioperative bleeding. A literature search of Medline between 1966 and 2005 was performed to identify appropriate studies. Studies that contained enough data to allow the calculation of the predictive value and likelihood ratios of tests for perioperative bleeding were included. Nine observational studies (three prospective) were identified. The positive predictive value (0AE03-0AE22) and likelihood ratio (0AE94-5AE1) for coagulation tests indicate that they are poor predictors of bleeding. Patients undergoing surgery should have a bleeding history taken. This should include detail of previous surgery and trauma, a family history, and detail of anti-thrombotic medication. Patients with a negative bleeding history do not require routine coagulation screening prior to surgery.Keywords: surgery, coagulation screen, bleeding, clinical history. ObjectiveThe aim of this guideline is to provide a rational approach to the use of bleeding history and coagulation tests prior to surgery or invasive procedures to predict bleeding risk. The aim is to evaluate the use of indiscriminate testing. Appropriate testing of patients with relevant clinical features on history or examination is not the topic of this guideline. The target population includes clinicians responsible for assessment of patients prior to surgery and other invasive procedures. MethodsThe writing group was made up of UK haematologists with a special interest in bleeding disorders and an anaesthetist. First, the commonly employed coagulation screening tests were identified and their general and specific limitations considered. Second, Medline was systematically searched for English language publications from 1966 to September 2005. Relevant references generated from initial papers and published guidelines/reviews were also examined. Meeting abstracts were not included. Key terms: routine, screening, preoperative, surgery, coagulation testing, APTT, PT, bleeding, invasive procedures. Inclusion criteria: studies had to contain enough data to enable the calculation of (i) the predictive value (PV) and likelihood ratio (LR) of the coagulation test for postoperative bleeding and/or (ii) the PV and LR of the bleeding history for postoperative bleeding. The rationale and methods for the calculations are described in Appendix 1. Nine observational case series with usable data (Table I) and one systematic review were identified (Table II).Data elements extracted from these articles were study type, surgical setting, number and age of patients and coagulation tests performed. Outcome data extracted included abnormal tests, positive bleeding history,...

Age-associated developmental changes in the activated partial thromboplastin time (APTT) and causes of prolonged APTT values in healthy Chinese children

“…These data will be helpful for accurate diagnosis and management of neonates and children with suspected bleeding or clotting disorders. Although routine coagulation testing to predict postoperative bleeding risk in unselected patients prior to surgery or other invasive procedures is not recommended (36,50), our results combined with bleeding scores from structured clinical histories (36,50) should reduce investigation of otherwise healthy Chinese children who are found to have mildly increased APTT values compared with adults, where routine coagulation tests are performed according to regulations.…”

Preoperative evaluation of adult patients before elective, noncardiothoracic surgery

“…Even the seriousness of the intervention and the age of the patient do not represent scientifically proven indications for preoperative laboratory tests per se. This also applies to determination of blood coagulation parameters [15]. Conventional coagulation tests (activated partial thromboplastin time, aPTT; international normalized ratio, INR; platelet count) are unable to detect the most frequent coagulopathies (congenital and acquired disorders of platelet function and the von Willebrand factor).…”

“…Normal values do not, therefore, exclude hemorrhagic diathesis. Coagulation tests are thus only recommended on the basis of a corresponding medication history (e. g., oral vitamin K antagonists) and where there is clinical suspicion of a coagulopathy, e. g., based on a positive bleeding history as assessed by a standardized questionnaire [15,16].…”

MRT der Prostata: Empfehlungen zur Vorbereitung und Durchführung

“…It is recommended in the S3 guidelines for men starting at age 45. The probability of the presence of prostate cancer increases as the PSA value increases.…”

“…Conventional coagulation testing with International Normalized Ratio (INR), activated partial thromboplastin time (aPTT), and thrombocyte number is a poor predictor of the intraoperative bleeding risk and is not capable of detecting the most common blood coagulation disorders (von Willebrand factor deficiency and thrombocyte dysfunction) [45]. A standardized questionnaire for recording bleeding history, prior operations and traumas, familial bleeding diathesis, and coagulation-inhibiting medication is therefore essential.…”