Preoperative unexpected prolongation of the activated partial thromboplastin time and prothrombin time in adults. Do we need to pursue abnormal results? A retrospective analysis

Abstract

BackgroundPreoperative coagulation screening tests are still performed often to assess bleeding risk; however, the effectiveness of this practice is a matter of debate and no longer recommended by some professional societies. We aimed to assess the management of unexpected prolonged activated partial thromboplastin time (APTT) and/or prothrombin time (PT) prior to elective surgery, and the perioperative hemorrhagic outcomes. MethodsThis was a retrospective cohort study conducted at a tertiary care hospital in Madrid, Spain. Patients who attended a preoperative anesthesia consultation between January 2013 and December 2018 were selected. 45,223 patients were screened for eligibility. After excluding children and patients with a preexisting cause for abnormal coagulation or who were receiving anticoagulation therapy, 722 adults with prolonged APTT and/or prolonged PT in coagulation screening tests were included in the study. Patients were grouped according to whether they were referred for a Hematology consultation or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. Results271 patients (38.5%, 95% CI 34.9 to 65.1) were referred to a Hematologist while 433 (61.5%, 95% CI 57.9 to 65.1) did not undergo further investigation. In 95% of the patients referred for a Hematology consultation, no significant hemostatic disorders were detected. No difference in perioperative hemorrhagic outcomes were found between the two groups. Additional studies were associated with a follow up pre-anesthetic evaluation median delay of 36,5 days (IQR 28 to 49) and a total referral cost of 45 596 euros ($ 54,100). ConclusionsFurther investigations of APTT and PT prolongations did not have any benefit in terms of hemorrhagic complications, and were associated with a significant preoperative delay and increase of healthcare costs. We recommend the more beneficial and cost-effective approach of selective preoperative coagulation testing based on bleeding history.