Preoperative Coagulation Screening Research Articles

Medical History and Preoperative Coagulation Profile as Predictors of Outcomes in Elective Spinal Surgery: A Meta-Analysis

In patients with unremarkable medical history, comprehensive preoperative hemostasis screening in elective neurosurgery remains debated. Comprehensive medical history has shown to be noninferior to coagulation profile to evaluate surgical outcomes. This study aims to evaluate the predictiveness of preoperative coagulation screening and medical history for surgical outcomes. Databases were searched until April 2023 for observational cohort studies that reported preoperative hemostasis screening and clinical history prior to elective neurosurgical procedures. Outcomes of interest included postoperative transfusion, mortality, and complications. Pooled relative risk ratios (RRs) were analyzed using random-effects models. Out of 604 studies, 3 cohort studies met our inclusion criteria, adding a patient population of 83,076. Prolonged partial thromboplastin time (PTT; RR=1.42, 95% confidence interval [CI]=1.14, 1.77, P=0.002), elevated international normalized ratio (INR; RR=2.01, 95% CI=1.14, 3.55, P=0.02), low platelet count (RR=1.58, 95% CI=1.34, 1.86, P<0.00001), and positive bleeding history (RR=2.14, 95% CI=1.16, 3.93, P=0.01) were associated with postoperative transfusion risk. High PTT (RR=2.42, 95%CI=1.24, 4.73, P=0.010), High INR (RR=8.15, 95% CI=5.97, 11.13; P<0.00001), low platelet count (RR=4.89, 95% CI=3.73, 6.41, P<0.00001), and bleeding history (RR=7.59, 95% CI=5.84, 9.86, P<0.00001) were predictive of mortality. Prolonged PTT (RR=1.53, 95% CI=1.25, 1.86, P=<0.0001), a high INR (RR=3.41, 95% CI=2.63, 4.42, P=< 0.00001), low platelets (RR=1.63, 95% CI=1.40, 1.90, P=<0.00001), and medical history (RR=2.15, 95% CI=1.71, 2.71, P=<0.00001) were predictive of complications. Medical history was a noninferior predictor to coagulation profile for postoperative transfusion, mortality, and complications. However, our findings are mostly representative of elective spinal procedures. Cost-effective alternatives should be explored to promote affordable patient care in patients with unremarkable history.

Exploring the milestones in anaesthesia that made liver transplantation a realistic therapeutic option for fatal liver failure: A story of 4 decades in a single centre

Liver transplantation has evolved from an initial experimental procedure to a successful treatment for end-stage liver disease. This study explored milestones in liver transplantation anaesthetic care that contributed to improved outcomes in a single centre.An analysis of transplant mortality outcomes was performed on adults and children who underwent liver transplantation between 1988 and 2019. A qualitative enquiry involved a thematic analysis of the opinions of retired and current anaesthetists.Four overarching themes were identified:•The evolving status of liver transplantation service•The importance of multi-disciplinary teams•The surgical process•The experimental nature of liver transplantationOf 5398 liver transplants performed, 23% were paediatric. Kaplan-Meier survival curves for adult and paediatric recipients showed a 1-year survival probability of over 90%. The 25-year survival was 42% and 80%, respectively.Improved management of (a) intraoperative blood loss through the use of techniques such as preoperative coagulation screening, intraoperative blood salvage, and the use of blood transfusions (b) enhanced intraoperative monitoring through the use of techniques such as continuous echocardiography, transesophageal echocardiography, and pulmonary artery catheters and (c) the establishment of dedicated theatre space and staff for liver transplantation achieved through the construction of new dedicated liver transplantation units and the hiring of specialized staff were the key anaesthetic milestones that contributed to improved patient outcome following liver transplantation.

Preoperative coagulation screening tests in pediatric patients: Clinical relevance and hemorrhagic outcomes of abnormal results.

Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes. Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. 1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8 to 538.5, P = 0.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology. Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.

Association between isolated abnormal coagulation profile on transfusion following major surgery: A NSQIP analysis of individuals without bleeding disorders.

Preoperative coagulation screening for patients without bleeding disorders remains controversial. The combinatorial risk of INR, aPTT, and platelet count (PLT) abnormalities leading to bleeding requiring transfusion is not known in these patients. We examined the association between abnormal coagulation profile and the risk of transfusion following common elective surgery in patients without bleeding disorders. We utilized the National Surgical Quality Improvement Program (NSQIP) database from 2004 to 2018 to identify patients without a history of bleeding disorders undergoing common 23 major elective procedures across 10 specialties. Multivariable logistic regression was used to assess the association between coagulation profile and bleeding requiring packed red blood cell transfusion intra-/post-operatively. Of the 672,075 patients meeting inclusion criteria, 53.7% presented with normal coagulation profile preoperatively. Overall, 12.2% (n=82,368) received transfusion. In the setting of normal aPTT/PLT, both Equivocal INR of 1.1-1.5 (aOR 1.41, 95% CI 1.38-1.44) and Abnormal INR of >1.5 (aOR 1.81, 95% CI 1.71-1.93) were significantly associated with an increased risk of transfusion. Equivocal (60-70) and Abnormal (>70) aPTT with normal INR/PLT did not demonstrate a comparable risk of transfusion. We observed a synergistic effect of combinatorial lab abnormalities on the risk of transfusion when both Abnormal INR/aPTT and Low PLT of <100,000 were present (aOR 5.18, 95% CI 3.04-8.84), compared to the effect of Abnormal INR/aPTT and normal/elevated PLT (aOR 1.90, 95% CI 1.48-2.45). The preoperative presence of abnormal findings in INR or PLT was significantly associated with the risk of bleeding requiring transfusion during intraoperative and postoperative periods.

765 Preoperative Coagulation Screening Audit in General Surgery

Abstract Aim Routine preoperative coagulation screening is considered standard practice to predict peri-operative bleeding. However, according to British Society of Haematology, indiscriminate coagulation screening is not recommended as it may to inappropriate delay of surgery, lead to further unnecessary tests and is also associated with significant costs. Instead, they recommend detailed bleeding history, including family history and use of medications. This audit was to evaluate the current practice and improve. Method A retrospective audit of 148 post-operative patients, randomly selected in Northwick Park Hospital admitted under the General Surgery between 01.04.2021 to 14.05.2021 at the initial audit and between 20.09.2021 to 07.10.2021 at the re-audit. Results The initial audit was done over a 6-week period with 98 cases selected. 19% of them had appropriate requests with 81% of the tests done being inappropriate. There was significant improvement by the re-audit with appropriate requests increasing to 56% and inappropriate tests dropping at 44%. The criteria for appropriate were a) Not requested as no significant medical history. b) Requested as clinically indicated. With each coagulation screening costing an average of £29.42, an overall estimate of £2971.42 was expended in inappropriate requests Conclusion All patients had relevant blood requests and PMH were documented but many inappropriate requests were made. It was recommended that instead of indiscriminate coagulation testing, a thorough history was advised to determine appropriate testing. There was a marked improvement at the re-audit with more appropriate requests being made. Recommendations Further meetings with the Anaesthesiologists to ensure a joint effort in achieving the target goal

TH7.7 Pre-operative Coagulation Screening in General Surgery

Abstract Aim Routine preoperative coagulation screening is considered standard practice to predict peri-operative bleeding. However, according to British Society of Haematology, indiscriminate coagulation screening is not recommended as it may to inappropriate delay of surgery, lead to further unnecessary tests and is also associated with significant costs. Instead, they recommend detailed bleeding history, including family history and use of medications. Methodology A retrospective audit of 148 post-operative patients in Northwick Park Hospital admitted under the General Surgical who presented to Surgical Assessment Unit between 01.04.2021 to 14.05.2021 at the initial audit and between 20.09.2021 to 07.10.2021 at the re-audit. Results The initial audit was done over a 6 week period with 98 cases selected. 19% of them had appropriate requests with 81% of the tests done being inappropriate. There was significant improvement by the re-audit with appropriate requests increasing to 56% and inappropriate tests dropping at 44%. The criteria for appropriate were: a) Not requested as no significant medical history. b) Requested as clinically indicated. With each coagulation screening costing an average of £29.42, an overall estimate of £2971.42 was expended in inappropriate requests Conclusion All patients had relevant blood requests and PMH were documented but many inappropriate requests were made. It was recommended that instead of indiscriminate coagulation testing, a thorough history was advised to determine appropriate testing. There was a marked improvement at the re-audit with more appropriate requests being made. Recommendations

TU7.2 Preoperative Indications for Coagulation Screening in the Elective Setting- A Single Centre Review

Abstract Aim NICE Guidelines 2016 state that coagulation screens should be carried out in all patients with chronic liver disease, anticoagulation use or those with an ASA 3 or 4. We aimed to review coagulation screening in elective patients according to current guidelines. Methods A single centre, retrospective review was carried out over a 3 month period, of patients undergoing elective procedures in a district general hospital. Data was retrieved from an institutional data base, with follow up information reviewed in an up to date electronic data base. Results 64 patients were included with a median age 41 years (range 19–85) and 56.3% male. Nineteen patients had an ASA of 3 or 4, however only one of these patients underwent a pre-operative coagulation screen. Four patients were taking anticoagulation medication prior to their procedure, however only one patient underwent pre-operative screening. Neither of these patient groups experienced any intra or post- operative bleeding. 3.1% of patients within the cohort experienced bleeding, all without pre-operative coagulation screening. Overall, screening was indication in 39.1% of patients, but was only performed in 3.1%. Conclusion Whilst a small number of patients within this study had bleeding related complications, it is evident that recommendations for patients with ASA 3 and 4 or those on anticoagulation therapy are not being met. Teaching and education on these guidelines will be provided and a further audit cycle completed.

Coagulation Screening in Patients Admitted to the Acute Surgical Receiving Unit - Ninewells Hospital, Dundee, Scotland

Introduction: Establish whether compliance to guidelines for routine pre-operative coagulation screening set by the National Institute for Health and Care Excellence (2016) is used on general surgical patients. Observe set components from guidelines with respect to the admission, dependent on grade of surgery and patient’s ASA grade. To determine financial loss per year from inappropriate/unnecessary coagulation testing performed on patients. Method: Review of all coagulation screening bloods taken for general surgical admissions to the acute surgical receiving ward over a 2 week period. The cost of one coagulation screen in NHS Tayside is £2.69. Clinical notes were reviewed in order to determine if criteria was met for performing a coagulation screening on admission. The results of the initial audit were presented at the Clinical Effectiveness meeting. The audit was repeated 2 weeks following a teaching session. Results: 200 individuals were included in the first cycle of the audit. It was found that 168 tests were ordered (161 unnecessary, 7 correctly screened, and 32 patients excluded appropriately). During the re-audit 208 patients were involved, and 153 tests were performed (151 unnecessary, 2 correctly screened, 55 patients excluded appropriately. Conclusion: As a result of the audit, coagulation screen sampling had decreased from 80.5% to 72.6%, an improvement of 7.9%. This equated to a savings of £26.90 over the duration of audit period (£699.20 per annum). This audit has demonstrated a change in clinical practice with potential significant financial benefit for the NHS.

Bleeding Risk Using INR/aPTT Pre-Surgery: Systemtic Review (BRUISR) (BRUISR)

Background:Multiple published studies have shown that abnormal coagulation tests, the prothrombin time (PT) and activated partial thromboplastin time (aPTT), are not helpful in predicting peri-operative bleeding. Despite numerous guidelines suggesting against their use, these tests continue to be ordered routinely in many pre-operative or pre-interventional settings.Objective:Our objective was to systematically assess the utility of unselected pre-operative PT and aPTT testing to predict bleeding outcomes.Data sources:We conducted a systematic literature review of MEDLINE, EMBASE and Evidence-based Medicine databases for articles published between 1970 and 2016 that addressed pre-operative and/or pre-interventional coagulation testing that was conducted in unselected fashion (i.e. not directed by the patient's personal/family history). Two independent reviewers (LL and AL) screened 3373 articles and 207 studies were included for full-text review.Study eligibility criteria:The minimum criteria for the 54 articles included in our qualitative analysis were: adult and/or pediatric patients undergoing elective surgery and/or an interventional procedure with pre-operative coagulation test results (PT and/or international normalized ratio (INR) and/or aPTT).Outcomes:The primary outcome was to examine the relationship between pre-operative coagulation results and peri-operative bleeding. As a secondary outcome, we also included studies that reported on the frequency of abnormal tests in routinely screened pre-operative patients as well as studies that described the cost of testing.Results:Of the 54 articles we included in our systematic review, studies were grouped according to procedure type: cardiac surgery (N=13), liver transplant (N=7) and tonsillectomy (N=13), major surgery (as defined in Choosing Wisely Canada, 2016) (N=12), and minor surgery (N=9). Within the combined studies of tonsillectomy and minor surgery categories, a total of 21 studies (after exclusion of 4 for insufficient data), there was only 1 study that showed an association between abnormal pre-operative coagulation testing and bleeding outcomes. Of the other 20 studies, 11 studies found no association between pre-operative coagulation studies and bleeding events, 4 studies had no bleeding events identified, 4 showed poor sensitivity of testing and 1 had no statistical information provided. In the major surgery category, there were a total of 26 studies (which included studies on liver transplant and cardiac surgery patients); only 4 studies identified an association between pre-operative coagulation testing and bleeding events, 17 found no association, and 4 described poor sensitivity of testing. In the studies that showed an association between pre-operative coagulation testing and bleeding, many used subjective definitions of bleeding, clinically insignificant thresholds to define abnormal aPTT and/or INR or provided insufficient data to support their conclusion. In summary, of the 45 studies with data on bleeding outcomes, the majority (71%) showed no association between bleeding events and pre-operative coagulation testing (Figure 1). As for assessment of quality, there were no randomized controlled trials (RCT) identified and the majority of observational studies were deemed at high risk of biasConclusion:To our knowledge, this is the largest systematic review that assesses the utility of pre-operative coagulation screening as a predictor of perioperative bleeding. Of the 54 studies that met our eligibility criteria, only 5 showed an association between coagulation test results and perioperative bleeding. Our findings support current guidelines which caution against unselected pre-operative coagulation testing and also emphasize the need for a well-designed and powered prospective cohort study or RCT to definitively answer this important question. [Display omitted] DisclosuresHicks:Gilead Sciences: Research Funding. Sholzberg:Octapharma: Honoraria, Research Funding; Shire: Honoraria, Research Funding; CSL Behring: Honoraria, Research Funding; NovoNordisk: Honoraria.

Age-Associated Changes of Coagulation Test and Coagulation Factor Activities in Healthy Chinese Children

Background: The concept of developmental hemostasis has been universally accepted. Plasma concentrations of many coagulation factors in childhood are significantly different from adults for both mean values and ranges of normal. Thus, an understanding of developmental hemostasis and the development of appropriate age-dependent reference ranges are pivotal for prevention, diagnosis, and treatment of hemostatic problems during childhood. However, no data of developmental hemostasis are available in healthy Chinese children. Methods: Coagulation data from children aged 0-18 years old receiving minor elective surgery in Chengdu Women and Children's Central Hospital, from Sep. 2017 to Feb. 2019 was collected, and patient medical records were reviewed. Ethical approval was obtained from the parents of all children and the study was approved by the Ethics Review Committee at Chengdu Women and Children's Central Hospital. To qualify for the study, enrolled subjects had to meet the following criteria: (1) Children aged 0-18 years receiving minor elective surgery.(2) No history of bleeding problems.(3)No family history of bleeding nor thrombosis .(4) No history of heart, lung, liver or kidney diseases, normal physical examination. (5) Normal blood routine test. Normal liver function and kidney function, (6)No history of medication use for at least two weeks prior to specimen collection.(7) The operation gone successfully, and postoperative recovery was well. Blood samples (3 mL) were obtained by venipuncture into plastic tube containing 3.2% (109 mmol/L) buffered sodium citrate (1 part citrate:9 parts blood). The specimens were centrifuged immediately at 2500 g for 15 min at room temperature to prepare platelet-poor plasma (PPP) for the preoperative coagulation screening tests, consisting of activated partial thromboplastin time (APTT), prothrombin time (PT)), international normalized ratio (INR), thrombin time (TT) and fibrinogen. Activity of coagulation factors VIII, IX, XI, XII,Ⅱ,Ⅴ,Ⅶ,Ⅹ were determined using one-stage clotting methods with respective factor-deficient plasma. Results: A total of 82 samples were collected, while only 67 met the enrollment criteria. Specimens with inappropriate ratio of blood to anticoagulant, hemolysis or abnormal values of coagulation tests (APTT, PT, TT, fibrinogen) were excluded from analysis. The total of 67 children (40 Male 27 female), with a median age of 2.0 years (range: 1month -14 years) were divided into three groups according to the age: &lt;1y group 15 cases, 1-5y group 45 cases, and &gt;6y group 7cases. (1) The values of APTT, PT, TT, and fibrinogen were (36.1±5.2) seconds, (11.1±0.85) seconds, (20.3±1.6) seconds, (2.4±0.89) g/L respectively. No significant differences were found between groups. (2) In all children ,the activities of factor VIII、IX、XI、XII、vWF、II、V、VII、X were(123.6±48.3)%、(75.9±16.9)%、(95.9±24.3)%、(43.7±16.3)%、(111.3±50.4)%、(90.2±14.0)%、(104.7±21.1)%、(81.6±19.1)%、(93.0±21.8)% respectively. Factor VIII and vWF activities were significantly higher than other factors, while factor XII activities were significantly lower than others. (3)Mean values of FII:C, FVIII:C, FIX:C, FXI:C were significantly lower in children below &lt;1year old group than those in 1-5y group. No significant difference were seen in FVII:C, FV:C, FX:C, FXII:C, vWF:C among three groups. Conclusions: Coagulation test is just a simple and easy screening test. Coagulation factor activities changed dynamically with age during childhood, especially the FII:C, FVIII:C, FIX:C and FXI:C. Physiological reference ranges for coagulation factor activities in Chinese children of different ages should be established in order to evaluate the children with congenital or acquired bleeding diseases correctively. Table Disclosures No relevant conflicts of interest to declare.

Preoperative screening for coagulopathy in elective neurosurgical patients in Wellington Regional Hospital and survey of practice across Australia and New Zealand

It is common practice to perform pre-operative coagulation screening in elective neurosurgery patients, including international normalised ratio (INR) and activated partial thromboplastin time (aPTT). We present a retrospective analysis of 1143 elective neurosurgical patients at Wellington Regional Hospital (WRH) in New Zealand between 2013 and 2017 on whom coagulation screening including INR and aPTT was performed prior to surgery. 21 patients (1.8%) had clinically significant derangements on coagulation profile defined as raised INR or prolonged aPTT. 15 (1.3%) of these patients would be expected to have derangement based on previous history and 6 (0.5%) had unexpected derangements in coagulation profile. Of the 6 patients with unexpected derangements in coagulation profile, all had raised aPTT, none had preoperative correction of coagulopathy and none had bleeding complications or mortality. The cost of coagulation screening across the duration of the study was $68,009 New Zealand Dollars (NZD). A survey of major elective neurosurgery units in Australia and New Zealand found that 85% perform routine laboratory coagulation screening. In the 15% who do not perform laboratory coagulation screening, none use a standardised questionnaire to screen for coagulopathy. We developed a structured questionnaire to assist in detection of coagulopathy in elective neurosurgery patients. Our findings suggest that there is limited value in performing indiscriminate laboratory coagulation screening in patients with no risk factors on history. Despite this, routine laboratory coagulation screening is common practice in Australia and New Zealand. We propose a structured questionnaire to guide laboratory testing and discussions with haematology colleagues.

Routine Preoperative Coagulation Tests in Children Undergoing Elective Surgery or Invasive Procedures: Are They Still Necessary?

Introduction:Preoperative coagulation screening tests in pediatric patients was once routine clinical practice globally and still used as standard practice in some countries before surgical procedures to assess of perioperative bleeding risk.Objective:The study aimed to evaluate unselected routine preoperative coagulation testing in children undergoing elective or invasive surgery to predict abnormal perioperative bleeding. The study also aimed to provide a rational approach of determining bleeding and family history of coagulation disorders as a predictive risk for bleeding.Methods:This retrospective study conducted between 2014 and 2015 (1 year) on normal healthy children aged under 15 years admitted to the hospitals for elective mild to intermediate surgery or invasive procedures. We reviewed and collected the details of the clinical history, previous surgery, trauma, family history, detail of anti-thrombotic medication and coagulation tests performed (prothrombin time (PT), the activated partial prothrombin time (APTT), and international normalized ratio (INR)) at the time of admission.Results:Among 2078 cases, 1940 cases had normal coagulation tests (93.4%), 77 cases had abnormal coagulation results (3.7%), and 61 patients underwent surgery without preoperative coagulation screening (2.9%). In 15 of 77 patients, coagulation tests were normal on repeat testing. A total of 52 were confirmed to have abnormal screening testing. Among these 52 cases, 45 had normal factors assay; where seven patients had abnormal factors assay. Postoperative bleeding occurred only in three cases (0.14%), two cases due to surgical procedures with normal preoperative testing and one due to hemophilia A which was detected postoperatively as no preoperative testing was performed.Conclusions:Routine coagulation screening before surgery or invasive procedures to predict perioperative bleeding in unselected patients is not recommended. Our study emphasizes that selective preoperative testing is more appropriate. Selective criteria for consideration of the latter includes physical examination, type of surgery, family and bleeding history, and concomitant use of antiplatelet and anti-thrombotic therapy.

Bleeding after tonsillectomy

Oropharyngeal hemorrhage after tonsillectomy is one of the most common postprocedural ENT emergencies that require immediate attention. Management choices depend on the severity of bleeding, underlying platelet or coagulation disorders, and the patient’s maturity and age. Treatment range from simple observation to an emergent need to both secure the airway and stop the hemorrhage. The workup of the hemorrhagic patient will be discussed from the preoperative to postoperative time period. Surgical techniques in response to various acuity will be discussed to fully elucidate options to control the hemorrhage.

The Benefit for Preoperative Coagulation Screening Test in Children

Methods: We retrospectively evaluated laboratory and bleeding histories in 39,884 patients aged greater than 1 year and lesser than 19 years who had undergone elective surgery from January 2003 to March 2015. All of the patients had preoperative coagulation screening with complete blood count, prothrombin time (PT) and activated partial thromboplastin time (aPTT). If PT and/or aPTT were abnormal, further studies, such as mixing test, coagulation factor assay, anti-phospholipid antibody studies were done.

Omitting pre-operative coagulation screening tests in hip fracture patients: Stopping the financial cascade?

BackgroundCoagulation screening continues as a standard of care in many hip fracture pathways despite the 2011 guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) which recommend that such screening be performed only if clinically indicated. This study aims to evaluate the use of pre-operative coagulation screening and explore its financial impact. MethodsProspective data was collected in accordance with the “Standardised Audit of Hip Fractures in Europe” (SAHFE) protocol. All patients admitted to our hospital with hip fractures during a 12-month period from November 2011 to November 2012 were analysed. Data including coagulation results and the use of vitamin K or blood products were collected retrospectively from the hospital computer system. Patient subgroup analysis was performed for intraoperative blood loss, post-operative blood units transfused, haematoma formation and gastrointestinal haemorrhage. Results814 hip fractures were analysed. 91.4% (n=744) had coagulation tests performed and 22.0% (n=164) had an abnormal result. Of these, 55 patients were taking warfarin leaving 109 patients who had abnormal results and were not taking warfarin. When this group (n=109) was compared to those who had normal test results (n=580) and to all other patients (n=705) there was no difference in intraoperative blood loss (p=0.79, 0.78), postoperative transfusion (p=0.38, 0.30), postoperative haematoma formation (p=0.79, 1.00), or gastrointestinal haemorrhage (p=0.45, 1.00), respectively. In those who were not taking warfarin, but had abnormal results, none had treatment to reverse their coagulopathy with either vitamin K or blood products. By omitting pre-operative coagulation tests in patients who are not taking warfarin, we estimate a financial saving of between £66,500 and £432,250 per annum. ConclusionsThis study supports the hypothesis that routine pre-operative coagulation screening is unnecessary in hip fracture patients unless they take warfarin or have a known coagulopathy. Moreover, its omission represents significant cost-saving potential.

Peritonsillarabszess - Analyse zu Rauchverhalten, präoperativer Gerinnungsdiagnostik und Therapie

Peritonsillar abscess (PTA) is a common problem in otorhinolaryngology. The pathogenesis, supporting factors and optimal therapy are matter of numerous investigations. We studied retrospectively smoking habits, preoperative coagulation screening and the applied therapy of PTA. Data from 460 patients who underwent treatment for PTA between 2000 and 2009 at Dessau Medical Center were retrospectively analysed. The highest incidence of PTA was found in young men, the prevalence of nicotine consumption was clearly increased in relation to the general population. The therapy of first choice was abscess tonsillectomy. Even with preoperative pathological coagulation-parameters no increased risk of secondary bleeding was shown. The part of smokers of patients with PTA is increased in comparison to the correspondent population of same age. A routine preoperative coagulation screening has a low benefit relating to the prediction of the risk of secondary bleeding. Abscess tonsillectomy is a safe method and has proved itself in clinical daily routine.

Clinical and Economic Impact of Pre-Operative Coagulation Screening in Children

AbstractAbstract 3379 Background:The literature in the past has recommended pre-operative (PRE-O) coagulation screening only when indicated by history or physical exam. Despite these recommendations, surgeons continue to order PT and PTT prior to surgery, especially in children, because they have often not been hemostatically challenged. We evaluated the usefulness of screening tests in identifying significant bleeding risk and associated cost. Methods:We performed a retrospective audit on children referred to the hemophilia center sent for further evaluation of abnormal PT and PTT on PRE-O screening. We reviewed 62 patients who had 80 procedures, out of which 70 procedures were evaluable with complete data. Age, personal and family history of bleeding, coagulation tests, PRE-O and post-operative (PO) treatment, and immediate PO bleeding were assessed. Results:The most common procedure that led to PRE-O screening was tonsillectomy/adenoidectomy at 61% (49/80). Other procedures included orthopedic, GI, oral, dental extractions, and myringotomies. Only 2.5% (2/80) were cardiac procedures. The mean patient age was 6 years (range 1–16). 55% (34/62) had no personal or family history of bleeding. 22.5% (14/62) had a family history of mild bleeding such as epistaxis or menorrhagia. 8% (5/62) had a family history of major bleeding disorders such as Von Willebrand disease (VWD) or hemophilia. 14.5% (9/62) had a personal history of bleeding, mild or major. The most common abnormal screening test was the PT at 40% (25/62). 27% (17/62) had an abnormal PTT (3.2% 262 with a significantly abnormal PTT above 50). 22.5% (14/62) were referred for abnormal PT/PTT. 8% (5/62) with an abnormal PT and/or PTT corrected on repeat studies. The remaining 9.6% (6/62) were referred for other reasons such as positive family or personal history and a high risk procedure. Additional coagulation tests ordered because of prolonged PT or PTT varied and included additional factor assays (Table 1). The mean cost of additional testing was >$1000.Abnormal Screening TestNumber of PatientsNumber of Additional Tests Per Patient (mode)Cost of Additional Testing Per Patient – US dollars (mean)Number of Patients with Post-Op bleedingPT254 (0–10)$1,0910PTT177 (1–7)$1,5880PT/PTT149 (3–9)$2,3180Factor VII was the most common factor deficiency identified with a mean activity of 47% (27–54%) (normal 55–163%) followed by factor XII deficiency with a mean activity of 39% ( 19–49%) (normal 46–168%). PRE-O, 5 patients received support with either Humate P, Stimate, Amicar, or DDAVP, 4 with a diagnosis of VWD and 1 with Jacobsen Syndrome; 3 of these patients received PO Amicar. PO, 69/70 procedures were completed with minimal (2–45 mL) bleeding. Only 1/70 procedures had significant PO bleeding, despite normal tests. This patient did not have any significant immediate PO bleeding, but had delayed bleeding reported at day 7 requiring cauterization. No other cases of delayed PO bleeding were reported to our clinic. Conclusion:In patients who undergo routine screening by laboratory testing only, the most common abnormality found was a prolonged PT. Subsequent workup of patients with abnormal screening tests identified factor VII or factor XII deficiencies most frequently. Only one patient with abnormal PT/PTT was diagnosed with a significant bleeding disorder, VWD. Major bleeding occurred rarely. This study demonstrates that the cost of extensive PRE-O coagulation testing is high with minimal clinical impact. Disclosures:No relevant conflicts of interest to declare.

Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

A60 Pre-Operative Coagulation Screening – Is it necessary for Neurosurgery?

A60 Pre-Operative Coagulation Screening – Is it necessary for Neurosurgery?

Significance and causes of abnormal preoperative coagulation test results in children

To prevent bleeding related to adenoidectomy and tonsillectomy, coagulation screening tests were, until recently, performed routinely in the Czech Republic for all paediatric patients. The aim of this study was to evaluate benefit of preoperative coagulation screening tests in children. We retrospectively analysed laboratory and clinical data of children referred for abnormal preoperative coagulation test results (aPTT, PT) to the outpatient haematology clinic. A total of 274 paediatric patients were retrospectively evaluated due to abnormal preoperative coagulation tests results. In 140 of 274 patients (51.1%), coagulation tests were normal on repeated testing in a specialized haematology clinic. Ten patients had decreased factor XII. Five patients had a suspected bleeding disorder which was confirmed in two of them. One patient had low levels of von Willebrand factor, and one patient had mild factor VII deficiency. Both these patients had positive personal and/or family history of bleeding. Each case history was taken individually, without use of standardized questionnaires. Bleeding complications were not observed, and coagulation factor replacement was not needed perioperatively in our cohort. The majority of abnormal findings in aPTT and PT appeared only transiently. All the bleeding disorders found in our cohort of patients were mild in nature. Our findings provide supportive evidence for the current national Czech recommendation: laboratory coagulation screening should be performed only in patients with positive family and/or personal bleeding history.