Preoperative Coagulation Research Articles

Rapid closure technique in suboccipital decompression

ObjectiveSuboccipital decompression has been established as standard therapeutic procedure for raised intracranial pressure caused by mass-effect associated pathologies in posterior fossa. Several different surgical techniques of dural closure have been postulated to achieve safe decompression. The aim of this study was to examine the differences between fibrin sealant patch (FSP) and dural reconstruction (DR) in suboccipital decompression for acute mass-effect lesions.MethodsWe retrospectively analyzed our institutional data of patients who underwent suboccipital decompression due to spontaneous intracerebellar hemorrhage, cerebellar infarction and acute traumatic subdural hematoma between 2010 and 2019. Two different dural reconstruction techniques were performed according to the attending neurosurgeon: (1) fibrin sealant patch (FSP), and (2) dural reconstruction (DR) including the use of dural patch. Complications, operative time, functional outcome and the necessity of a ventriculoperitoneal shunt (VP Shunt) were assessed and further analyzed.ResultsOverall, 87 patients were treated at the authors’ institution (44 in FSP group, 43 in DR group). Glasgow coma scale on admission and preoperative coagulation state did not differ between the groups. Postoperatively, we found no difference in cerebrospinal fluid leakage or chronic hydrocephalus between the groups (p = 0.47). Revision rates were 2.27% (1/44 patients) in the FSP group, compared to 16.27% (7/43) in the DR group (p < 0.023). Operative time was significantly shorter in the FSP group (90.3 ± 31.0 min vs. 199.0 ± 48.8 min, p < 0.0001).ConclusionRapid closure technique in suboccipital decompression is feasible and safe. Operative time is hereby reduced, without increasing complication rates.

Association of biomarkers related to preoperative inflammatory and coagulation with postoperative in-hospital deaths in patients with type A acute aortic dissection

The aim of this study was to analyze the role of blood biomarkers regarding preoperative inflammation and coagulation in predicting the postoperative in-hospital mortality of patients with type A acute aortic dissection (AAD). A total of 206 patients with type A AAD who had received surgical treatment were enrolled in this study. Patients were divided into two groups: the death group (28 patients who died during hospitalization) and the survival group (178 patients). Peripheral blood samples were collected before anesthesia induction. Preoperative levels of D-dimer, fibrinogen (FIB), platelet (PLT), white blood cells (WBC) and neutrophil (NEU) were compared between the two groups. Univariable and multivariable logistic regression analysis were utilized to identify the independent risk factors for postoperative in-hospital deaths of patients with type A AAD. Receiver operating characteristic (ROC) curve were used to analyze the predictive value of these indices in the postoperative in-hospital mortality of the patients. Univariable logistic regression analysis showed that the P values of the five parameters including D-dimer, FIB, PLT, WBC and NEU were all less than 0.1, which may be risk factors for postoperative in-hospital deaths of patients with type A AAD. Further multivariable logistic regression analysis indicated that higher preoperative D-dimer and WBC levels were independent risk factors for postoperative in-hospital mortality of patients with type A AAD. ROC curve analysis indicated that application of combining FIB and PLT could improve accuracy in prediction of postoperative in-hospital mortality in patients with type A AAD. Both preoperative D-dimer and WBC in patients with type A AAD may be used as independent risk factors for the postoperative in-hospital mortality of such patients. The combination of FIB and PLT may improve the accuracy of clinical prognostic assessment.

Perioperative Coagulation Monitoring.

The main goal of perioperative coagulation monitoring is to improve safety of patients undergoing surgical procedures. Various conditions can affect the coagulation system during surgery and bleeding. The value of traditional standard coagulation tests is limited in detecting hemostatic dysfunctions and they are particularly ineffective in diagnosing hyperfibrinolysis. This article reports on key issues and pathophysiologic changes that affect the hemostatic system in the perioperative setting. Values of preoperative coagulation tests are discussed and the basic principles for point-of-care coagulation devices, including platelet analyzers and their clinical use, are evaluated.

Aortic root repair in a patient with acquired hemophilia A: case report

BackgroundPatients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients.Case presentationA 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful.ConclusionCardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.

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

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.

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.

Assessment of laboratory tests and intraoperative bleeding in patients with liver cirrhosis undergoing tooth extractions

The objective of this study was to quantify intraoperative bleeding in patients with cirrhosis and correlate it with clinical characteristics and laboratory coagulation tests. A case-control study was carried out with 74 patients with cirrhosis who were submitted to preoperative coagulation tests (complete blood count, platelet count, prothrombin time/international normalized ratio, thrombin time, activated partial thrombin time, platelet aggregation, fibrinogen, protein C, protein S, antithrombin, and von Willebrand factor level and activity). The levels of nitrogen compounds that can affect the platelet function were determined in saliva and blood by using automated enzymatic-colorimetric assays. Patients with cirrhosis had changes in almost all coagulation tests. The average volumes of intraoperative bleeding and blood lost per minute in the study group (5.36 mL/min and 0.19 mL/min, respectively) were greater than those in the control group (3.05 mL/min and 0.11 mL/min, respectively; P < .05). In the control group, ascites (P=.012) and presence of periapical lesion (0.034) were positively correlated with bleeding (mL/min). With regard to coagulation tests and nitrogen compounds, only a positively moderate correlation with the platelet aggregation test was observed. No patients had hemorrhagic events and it was not possible to correlate a greater amount of bleeding with coagulation tests or nitrogen compounds in the study group.

Safety profile of preoperative administration of low-molecular-weight heparin on minimally invasive lung cancer surgery: a randomized controlled trial

BackgroundVenous thromboembolism remains a common but preventable complication for cancerous lung surgical patients. Current guidelines recommend thromboprophylaxis for lung patients at high risk of thrombosis, while a consensus about specific administration time is not reached. This study was designed to investigate the safety profile of preoperative administration of low-molecular-weight-heparin (LMWH) for lung cancer patients.MethodsFrom July 2017 to June 2018, patients prepared to undergo lung cancer surgery were randomly divided into the preoperative LMWH-administration group (PRL) for 4000 IU per day and the postoperative LMWH-administration group (POL) with same dosage, all the patients received thromboprophylaxis until discharge. Baseline characteristics including demographics and preoperative coagulation parameters were analyzed, while the endpoints included postoperative coagulation parameters, postoperative drainage data, hematologic data, intraoperative bleeding volume and reoperation rate.ResultsA total of 246 patients were collected in this RCT, 34 patients were excluded according to exclusion criterion, 101 patients were assigned to PRL group and 111 patients belonged to POL group for analysis finally. The baseline characteristic and preoperative coagulation parameters were all comparable except the PRL group cost more operation time (p = 0.008) and preoperative administration duration was significantly longer (p < 0.001). The endpoints including postoperative day 1 coagulation parameters, mean and total drainage volume, drainage duration, intraoperative bleeding volume and reoperation rate were all similar between the two groups. Moreover, coagulation parameters for postoperative day 3 between the two groups demonstrated no difference.ConclusionPreoperative administration of low-molecular-weight-heparin demonstrated safety and feasibility for lung cancer patients intended to receive minimally invasive surgery.Trial registration: ChiCTR2000040547 (www.chictr.org.cn), 2020/12/1, retrospectively registered.

Abnormal Coagulation as a Risk Factor for Postoperative Complications After Primary and Revision Total Hip and Total Knee Arthroplasty

BackgroundPatients undergoing total joint arthroplasty (TJA) have an increased likelihood of having an abnormal coagulation profile compared with the general population. Coagulation abnormalities are often screened for before surgery and considered during perioperative planning. This study assesses a preoperative abnormal coagulation profile as a risk factor for postoperative complications after total hip arthroplasty (THA), revision THA (rTHA), total knee arthroplasty (TKA), and revision TKA (rTKA) and then examines specific coagulopathies to determine their influence on complication rates. MethodsPatients who underwent THA, rTHA, TKA, or rTKA from 2011 to 2017 were identified in the American College of Surgeons National Surgical Quality Improvement Program database and then assessed for preoperative abnormal coagulation profiles. Various postoperative complications were analyzed for each cohort, and two separate multivariate regression analyses were used to assess the relationship between abnormal coagulation and postoperative complications. Results403,566 THA, rTHA, TKA, or rTKA cases were identified, and 40,466 (10.0%) of patients were found to have an abnormal coagulation profile. Patients with preoperative coagulation abnormalities had higher likelihoods of postoperative complications after primary TJA than in revision TJA. An international normalized ratio>1.2 was associated with the most types of postoperative complications, followed by a bleeding disorder diagnosis. A partial thromboplastin time>35 seconds was associated with only one type of postoperative complication, while a platelet count <150,000 per μL was associated with postoperative complications only after TKA. ConclusionTJA in patients with abnormal coagulation profiles may result in adverse outcomes. These patients may benefit from preoperative intervention. Prophylactic care needs to be personalized to the specific coagulation abnormalities present.

Bleeding risk of image-guided percutaneous catheter drainage of pyogenic liver abscess in patients with coagulopathy.

Percutaneous catheter drainage (PCD) is the mainstream treatment for pyogenic liver abscess (PLA). However, in some patients with severe coagulopathy, there may increase the risk of bleeding complications related to PCD. Therefore, this study was aimed to evaluate the incidence of bleeding complications of PCD in PLA patients complicated with coagulopathy. Between January 2011 and September 2019, patients diagnosed with PLA who had undergone PCD were selected retrospectively. Based on the preoperative coagulation parameters, the patients were divided into the coagulopathy group (PLT ≤ 50 × 109/L or INR ≥ 1.5) and the normal coagulation group. The major and minor bleeding complications related to PCD were compared between the two groups. The ICU occupancy and mortality rates in the coagulopathy group were assessed and compared with patients of normal coagulation group. A total of 583 PLA patients subjected to PCD were selected. 522 patients were finally included in this study: 64 cases (12.26%) in the coagulopathy group and 458 cases (87.74%) in the normal coagulation group. No major bleeding complications related to PCD was observed. Two patients (0.38%) of minor bleeding complications, one patient in each group, showed no statistically significant difference (0.2% vs.1.6%, P > 0.05). The ICU occupancy rate of coagulopathy group was significantly higher than normal coagulation group (6.2% vs. 0.7%, P < 0.05). No significant difference in mortality rate was noted between the two groups (4.7% vs.1.5%, P > 0.05). The incidence of bleeding complications related to PCD in PLA patients is rare even if complicated with coagulopathy.

The influences of selected clotting and fibrinolysis factors on survival of patients with kidney tumors - a prospective study.

Multiple studies suggest that cancer leads to activation of clotting and fibrinolysis pathways, elevating the risk of thromboembolic events. Kidney cancer is often complicated by clotting disorders. In this study, we hypothesized that preoperative clotting and fibrinolysis parameters are altered in healthy volunteers and kidney tumor patients. We also hypothesized that these differences may be associated with survival in patients who have undergone operations due to kidney tumors. In this study, 96 patients with kidney tumors and 30 healthy volunteers were recruited at a single university center. All patients were assessed for pre-operative serum concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI, total TFPI, full-length TFPI, truncated TFPI), plasmin-antiplasmin complex (PAP), thrombin-antithrombin complex (TAT), von Willebrand factor (vWF), clotting factor XIII A1 (FXIIIA1), D-dimers, and fibrinogen. Additionally, standard peripheral blood morphology was evaluated. Malignant kidney tumors were diagnosed in 85 of 96 tumor patients. In patients with kidney tumors, there were statistically significantly higher concentrations of fibrinogen, D-dimers, TAT, PAF, TF, TFPI, vWF, FXIIIA1, and leukocyte counts compared to the control group. Statistically significant correlations were found between multiple parameters. This points to significant clotting system alterations. Cox stepwise hazard analysis showed that pre-operative fibrinogen and D-Dimer concentrations were significantly associated with survival. In patients with kidney tumors, multiple clotting and fibrinolysis parameters are significantly altered. Routine pre-operative measures should include determination of fibrinogen and D-dimer concentrations as these markers aid in prediction of survival probability.

Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis.

To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis. Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes. In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 109/L. Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.

Effectiveness of Coagulation Profile as a marker for blood loss in Elective Craniotomy patients

Objective: The objective of this study is to determine the role of preoperative coagulation studies in predicting intraoperative blood loss, in patients undergoing elective craniotomy in our tertiary hospital setting. Materials and Methods: This was a Quasi-experimental study conducted at Department of Neurosurgery, Aga Khan University Hospital Karachi for a duration of 6 months. A non-probability consecutive sampling technique was employed. All admitted neurosurgery patients for elective craniotomy were enrolled and followed as part of the study. Laboratory values including baseline workup e.g. Complete Blood count, PT, activated Partial Thromboplastin Time (aPTT), Internationalized Ratio (INR) were taken preoperatively and postoperatively. A predesigned questionnaire for the collection of data was used, which included demographics and clinical information. Approval from the university ethical committee was obtained before starting the study. Data was entered and analysed into SPSS version 21. Effect modifier age, gender, co-morbids, type, and duration of surgery, were controlled through stratification. Post-stratification paired t-test and independent-sample t-test were applied using P ≤ 0.05 as significant.Results: In this study 57 patients who underwent elective craniotomy were included to assess the mean blood loss and to compare mean blood loss in patients with normal and deranged coagulation profiles. The mean age of patients included in the study was 39.36±13.94 years with 43 (75.4%) males and 14 (24.6%) females. The mean preoperative haemoglobin level amongst all patients turned out to be 14.10±3.98 gm/dl. The postoperative haemoglobin level showed a decrease with a mean of 12.68±31.98 gm/dl. Therefore the mean difference calculated between pre and post-operative haemoglobin levels turned out to be 1.42±0.99 gm/dl.Conclusion: It is to be concluded that significant change was found in preoperative and post-operative Haemoglobin levels in patients undergoing elective craniotomy. There was also a highly significant difference in blood loss between patients having a normal versus deranged coagulation profile. However, there is a need to conduct more studies using a large sample size with multiple study sites in Pakistan to validate these results.

Abstract P671: Association Between Liver Fibrosis and Postoperative Stroke

Introduction: Chronic liver disease is associated with aberrant hemostasis, resulting in an increased risk of clotting and bleeding. We hypothesized that liver fibrosis, a manifestation of progressive chronic liver disease, is associated with stroke among people who have been subjected to the hemostatic stress of surgery. Methods: We conducted a retrospective, multicenter cohort study using data from 680 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), a prospective registry of 30-day outcomes. Quality measures, such as stroke, have been validated and have 95% inter-observer agreement. We included adults who underwent major surgery, except neurosurgery, from 2005-2016. The exposure was the Aspartate aminotransferase to Platelet Ratio Index (APRI) liver fibrosis score, calculated from preoperative aspartate aminotransferase and platelet count. The primary outcome was incident stroke, reported by NSQIP as a composite of ischemic and hemorrhagic stroke. We used multivariable Cox proportional hazards models to assess the relationship between APRI and incident stroke, adjusting for demographics, comorbidities, and surgical characteristics (surgical type and American Society of Anesthesiologists preoperative fitness classification). In a sensitivity analysis, we also adjusted for preoperative platelet count and coagulation indices. Results: Among 2,729,995 patients, the mean age was 57 (SD, 17) years and 58% were women. A total of 6,886 patients had stroke within 30 days (0.25%). In unadjusted analyses, a 1-point increase in APRI was associated with a 3% increased risk of stroke (HR, 1.03; 95% CI, 1.02-1.03). The association remained significant in models adjusted for comorbidities and surgical characteristics (HR, 1.02; 95% CI, 1.01-1.03). Sensitivity analyses also adjusted for platelet count and coagulation indices were consistent (HR, 1.03; 95% CI, 1.01-1.04). Conclusions: A liver fibrosis score calculated from routine preoperative laboratory data was independently, albeit modestly, associated with an increased risk of stroke within 30 days after surgery. Whether preoperative assessment of liver disease markers has clinical utility requires investigation.

Perioperative Management of a Patient with Prosthetic Mitral Valve Posted for Ankle Surgery

Introduction: Patients with prosthetic valves pose a specific challenge to the anesthesiologist due to their increased predisposition to thrombo embolic events, infective endocarditis and hemolysis. Case Report: Here we describe the anaesthetic management of a 50 year old female with prosthetic mitral valve posted for wound debridement and external fixation for open type III right ankle bone fracture. She is a known case of Rheumatic heart disease and has underwent mitral valve replacement with tricuspid annuloplasty 5years back and is on oral anticoagualtion which was stopped 7days prior to surgery. Pre operative ECG showed AF with recent ECHO finding of concentric LVH with EF of 60%. Pre operative coagulation profile was normal. Antibiotic prophylaxis was given 2hours prior to incision. Case was done under general anaesthesia. Patient was induced with etomidate and maintained with intermittent doses of propofol and isoflurane with adequate analgesics. Intra operative blood loss was around 100ml.Patient was extubated and shifted to ICU for observation. Conclusion: In patients with prosthetic heart valves the most common complication is thromboembolism therefore optimising the coagulation profile before the surgery and subsequent restarting of anticoagulation therapy immediately after surgery is of utmost importance.

Preoperative heart failure is not associated with impaired coagulation in paediatric cardiac surgery.

The objectives of the present study were to determine whether there was any association between the grade of heart failure, as expressed by preoperative levels of brain natriuretic peptide and Ross score, and the preoperative coagulation status in patients with non-restrictive ventricular shunts and determine whether there were any postoperative disturbances of the coagulation system in these patients, as measured by thromboelastometry and standard laboratory analyses of coagulation. Perioperative coagulation was analysed with laboratory-based coagulation tests and thromboelastometry before, 8 hours after, and 18 hours after cardiac surgery. In addition, brain natriuretic peptide was analysed before and 18 hours after surgery. 40 children less than 12 months old with non-restrictive congenital ventricular or atrio-ventricular shunts scheduled for elective repair of their heart defects. All coagulation parameters measured were within normal ranges preoperatively. There was a significant correlation between brain natriuretic peptide and plasma fibrinogen concentration preoperatively. There was no statistically significant correlation between brain natriuretic peptide and INTEM-MCF, FIBTEM-MCF, plasma fibrinogen, activated partial thromboplastin time, prothrombin time, or platelet count at any other time point, either preoperatively or postoperatively. Postoperatively, fibrinogen plasma concentration and FIBTEM-MCF decreased significantly at 8 hours, followed by a large increase at 18 hours to higher levels than preoperatively. There was no evidence of children with non-restrictive shunts having coagulation abnormalities before cardiac surgery. Brain natriuretic peptide levels or Ross score did not correlate with coagulation parameters in any clinically significant way.

Unexpected upper limb compartment syndrome due to venous thrombosis in frontal glioma surgery: A case report

Although it is well known that 49% cases of upper limb deep-vein thrombosis are due to malignancies and the likelihood of venous thromboembolism is increased in patients with high grade gliomas due to the heightened prothrombotic milieu, requisite preoperative laboratory coagulation studies are not performed routinely in these patients to decide whether appropriate antithrombotic medications are required preoperatively. In addition, it is controversial whether antithrombotic therapy should be initiated before neurosurgery in view of the risk of intraoperative bleeding. Here, we have described the case of a 29-year-old female with high grade frontal malignant astrocytoma who developed the extremely rare complication of upper limb compartment syndrome postoperatively. The patient had no history of thrombotic events, and her basic laboratory parameters were not deranged in the pre-operative period. This rare case, supported with a literature review, suggested that the risk of thrombosis is increased in high grade and large gliomas, making us rethink the overall battery of investigations and perioperative medical management of such cases. We strongly recommend peri-operative coagulation studies and appropriate antithrombotic measures along with vigilant perioperative monitoring to avoid thrombotic complication in this subset of patients.

Usefulness of Routine Coagulation Tests in Healthy Children Undergoing Elective Minor Surgery: a 12-Year Retrospective Study.

Although routine coagulation tests, such as prothrombin time (PT) and activated partial thromboplastin time (aPTT) are performed before surgery to identify the risk of perioperative bleeding, bleeding complications are rare in minor surgeries, and false-positive results are often observed. Therefore, this study aimed to analyze the common causes of abnormal results of preoperative coagulation tests in previously healthy children undergoing elective minor surgery and determine the usefulness of performing these tests. Additionally, it aimed to identify the distribution of factor XII activity in children with prolonged aPTT. The medical records of 363 pediatric patients aged 0 - 18 years, who were referred to the pediatric hematology-oncology department due to abnormal preoperative coagulation tests prior to undergoing minor surgery at the Kyung Hee University Medical Center between March 2008 and October 2020, were retrospectively review-ed. The majority of patients (n = 348, 96%) had prolonged aPTT, few (n = 29, 8%) had a prolonged PT international normalized ratio, and a small number (n = 14, 4%) had both prolonged PT and aPTT. On repeating the coagulation tests, 194 children showed persistent abnormal results. Of these, 184 patients underwent mixing tests, and 176 showed correction for factor deficiency (n = 26) and lupus anticoagulant positive (n = 14). Factor deficiencies included factor XII (n = 16), possibility of von Willebrand disease (vWD; n = 4), factor XI (n = 2), factor VIII (n = 1), factors IX and XII (n = 1), factor VII (n = 1), and factor V (n = 1). The severity of factor deficiency was mild (25 - 38%). One patient with factor VII deficiency received preoperative clotting factors but had postoperative bleeding requiring clotting factor replacement. Another patient with possible vWD received fresh frozen plasma after surgery and had mild symptoms. Linear regression showed no significant correlation between factor XII activity and aPTT in patients with prolonged aPTT (R2 = 0.0002, p = 0.84) or factor XII activity according to aPTT results in those with factor XII deficiency (R2 = 0.04749, p = 0.40). These results suggest that coagulation tests may be selectively performed in previously healthy children undergoing minor surgery with positive bleeding and/or family history. The distribution of factor XII should be investigated further.

Coagulation Profile as a Significant Risk Factor for Short-Term Complications and Mortality after Anterior Cervical Discectomy and Fusion

Cervical degenerative disc disease is the most common indication for anterior cervical discectomy and fusion. Given the possible complications, patients are stratified before anterior cervical discectomy and fusion by preoperative risk factors to optimize treatment. One preoperative factor is a patient's coagulation profile. The American College of Surgeons-National Surgical Quality Improvement Database was used to identify patient preoperative coagulation profile and postoperative complications. By generating binary logistic regression models, each of the 4 abnormal coagulation categories (bleeding disorder, low platelet count, high partial thromboplastin time, and high international normalized ratio [INR]) were analyzed for their independent impact on increased risk for complications compared with the control cohort. A total of 61,977 patients were assessed. The most common abnormal coagulation was abnormal platelet count (n= 2149). The most common postoperative outcome was an extended length of hospital stay among patients with an abnormal coagulation profile relative to the control cohort. After multivariate analysis, patients with an abnormal INR (odds ratio, 2.2 [1.3-3.8]; P= 0.003) or abnormal platelet count (odds ratio, 1.5 [1.2-2.1]; P= 0.003) had a higher chance of having an extended length of hospital stay relative to patients having a normal coagulation profile. Having an abnormal INR was found to be associated with an increased risk for having "Any complication." Our results show significant differences in the incidence rates of a multitude of complications among the 5 groups based on univariate analysis. Patients with any abnormal coagulation disorder had increased rates of developing any complication or having an extended length of hospital stay.

Bleeding Disorder Referrals to Hematology Clinic: A Single Institution Experience

BACKGROUND Our tertiary care pediatric hematology/oncology/BMT service receives hundreds of referrals yearly for bleeding disorder evaluation both due to bleeding symptoms and secondary to routine preoperative laboratory testing prior to elective surgery. The evaluation for a bleeding disorder can be challenging due to the wide variability of symptoms as well as the need for accurate interpretation of lab results. In 2014, Bhasin et al., Pediatric Hematology and Oncology showed that 4% of patients referred to hematology based on a preoperative coagulation evaluation had a clinically relevant bleeding disorder. Currently there is little literature about the referral patterns to pediatric hematology and the outcomes of these referrals. OBJECTIVES To characterize our hematology referrals for bleeding disorder, work up To describe the diagnostic outcomes from these referrals To estimate the proportion of bleeding disorders diagnosed from these referrals To identify referral factors that are associated with being diagnosed with a bleeding disorder DESIGN/METHOD This is a single center, retrospective chart review. Patients referred and or seen for a bleeding disorder evaluation at Children's Mercy Hospital from 07/1/2018 until 06/30/19 were evaluated for demographics, reason for consultation, referring provider, and outcome of referral. Akaike Information Criterion (AIC) was applied to logistic regression to identify factors associated with diagnosis of bleeding disorder. RESULTS A total of 373 patients were included and demographics are detailed in Table 1. Forty patients were diagnosed with a bleeding disorder, 78 patients were lost to follow up or have work up still in progress, and 255 patients had a bleeding disorder ruled out. Of our referred patient sample, 6% (21/373) were diagnosed with von Willebrand disease, 4% (14/373) were diagnosed with a platelet function disorder, and 1.3% (5/373) were diagnosed with a coagulation factor deficiency. The median time between referral and appointment was 31.5 days with a median of 2 total visits including clinic and laboratory visit for a clinical diagnosis. Forty percent of referrals were for preoperative clearance, 36% for family history, and 57% for symptoms. Of the patients referred for symptoms, 22.7% were referred for bruising and 83.9% for bleeding. Thirty eight percent had previously been treated for symptoms through hormone management, nasal cauterization, surgical intervention, or other methods. Forty four percent (164/373) of the referrals were from Otolaryngology, 30% from primary care including adolescent medicine and gynecology, and 27% from other specialties. Seventy percent of referrals were internal from specialties within our institution. The results indicate that the odds of a bleeding disorder diagnosis decrease by 8% for every year increment in age and was 3 times higher among patients having abnormal coagulation labs at the time of referral as compared to their counterpart when other variables were controlled. Logistic regression model showing referral factors that could be associated with bleeding disorder diagnosis are detailed in table 3. CONCLUSION This study characterizes the bleeding disorder referral patterns at our institution including the proportion of bleeding disorders diagnosed. This study also highlighted certain referral factors such as age, gender, referral for preoperative clearance, previous treatment with nasal cauterization and the presence of abnormal lab values that could be predictive of the presence of a bleeding disorder. Limitations of this study include the small number of patients with confirmed diagnosis and that it is conducted at a single center. Additionally, at our center, referrals are screened by a physician prior to being seen, which could have influenced the results. We illustrate that large-scale studies are needed to determine referral factors associated with the diagnosis of a bleeding disorder. Disclosures Carpenter: American Academy of Pediatrics: Other: PREP Heme/Onc editorial board; Hemostasis &amp; Thrombosis Research Society: Membership on an entity's Board of Directors or advisory committees; Shire: Research Funding; CSL Behring: Research Funding; American Thrombosis and Hemostasis Network: Membership on an entity's Board of Directors or advisory committees; Genentech, Inc.: Honoraria; Kedrion: Honoraria; Novo Nordisk: Honoraria.