Preoperative Assessment of HemostasisPreoperative Assessment of HemostasisOrOr

Stop Doing Bleeding Times! Stop Doing Bleeding Times!

Lt Col Lucia E. MoreLt Col Lucia E. MoreUnited States Air ForceUnited States Air Force

Why Not Bleeding Time?Why Not Bleeding Time?

Not reliable as a screening test Not reliable as a screening test Lack reproducibilityLack reproducibilityAffected by location of the incision, Affected by location of the incision,

pressure applied, operator experience, and pressure applied, operator experience, and patient factors such as age, gender, diet, patient factors such as age, gender, diet, hematocrit, skin laxity, medications, etc.hematocrit, skin laxity, medications, etc.

Why Not Bleeding Time?Why Not Bleeding Time?

In the absence of a clinical history of a bleeding In the absence of a clinical history of a bleeding disorder, the bleeding time is not a useful disorder, the bleeding time is not a useful predictor of the risk of hemorrhage associated predictor of the risk of hemorrhage associated with surgical procedures; with surgical procedures;

A normal bleeding time does not exclude the A normal bleeding time does not exclude the possibility of excessive hemorrhage associated possibility of excessive hemorrhage associated with invasive procedureswith invasive procedures. .

Recommendations for preoperative Recommendations for preoperative assessment of hemostasisassessment of hemostasis

Careful clinical history including family, dental, obstetric, Careful clinical history including family, dental, obstetric, surgical, traumatic injury, transfusion, and drug history. surgical, traumatic injury, transfusion, and drug history.

   Physical examination; findings suggestive of a potential Physical examination; findings suggestive of a potential

bleeding disorder; the presence of petechiae or bleeding disorder; the presence of petechiae or ecchymoses, telangiectasias, evidence of past ecchymoses, telangiectasias, evidence of past hemarthroses (joint deformities in a patient with a positive hemarthroses (joint deformities in a patient with a positive bleeding history), hematomas etc. bleeding history), hematomas etc.

   Evaluate specific surgical procedures and their bleeding Evaluate specific surgical procedures and their bleeding

risks. risks.

Low Risk SurgeryLow Risk Surgery

Nonvital organs are involved Nonvital organs are involved The surgical site is exposed The surgical site is exposed There is a limited degree of surgical dissectionThere is a limited degree of surgical dissection Local hemostatic measures are likely to be Local hemostatic measures are likely to be

effective effective The site does not have local fibrinolysisThe site does not have local fibrinolysis i.e. lymph node biopsy, herniorrhaphy, dental i.e. lymph node biopsy, herniorrhaphy, dental

extractionsextractions

Moderate/high risk surgical proceduresModerate/high risk surgical procedures

Prostatic surgery, tonsillectomy, oral or nasal surgery, Prostatic surgery, tonsillectomy, oral or nasal surgery, closed liver or kidney biopsy, cardiopulmonary bypass, closed liver or kidney biopsy, cardiopulmonary bypass, brain injury, extensive malignancy, laparotomy, brain injury, extensive malignancy, laparotomy, thoracotomy, mastectomy, neurosurgical and ophthalmic thoracotomy, mastectomy, neurosurgical and ophthalmic procedures, as well as surgical procedures employed to procedures, as well as surgical procedures employed to stop bleeding. Most laparascopic procedures would fall stop bleeding. Most laparascopic procedures would fall into this category as well (e.g., arthroscopic orthopedic into this category as well (e.g., arthroscopic orthopedic procedures, gynecologic laparoscopy, and laparascopic procedures, gynecologic laparoscopy, and laparascopic cholecystectomy or splenectomy).cholecystectomy or splenectomy).

So, what should we do instead?So, what should we do instead?

Small facilities: Small facilities: – Use flowchart to identify potential Use flowchart to identify potential

bleedersbleeders– Refer patient to larger facility/network Refer patient to larger facility/network

provider who can evaluate the patient provider who can evaluate the patient Larger labs: PFA 100Larger labs: PFA 100

PFA 100PFA 100

Combined measure of platelet adhesion and Combined measure of platelet adhesion and aggregation.aggregation.

Detection of congenital inherited and acquired platelet Detection of congenital inherited and acquired platelet dysfunctiondysfunction

Screens for von Willebrand diseaseScreens for von Willebrand disease Assesses the anti-platelet effect of AspirinAssesses the anti-platelet effect of Aspirin Evaluates platelet dysfunction in childrenEvaluates platelet dysfunction in children Evaluates platelet dysfunction in multiple clinical settings Evaluates platelet dysfunction in multiple clinical settings

such as high bleeding risk surgery, high-risk pregnancy such as high bleeding risk surgery, high-risk pregnancy and menorrhagia. and menorrhagia.

PFA 100PFA 100

Most common hemostatic disorders can be ruled Most common hemostatic disorders can be ruled out w/ PT/APTT, platelet count, platelet functionout w/ PT/APTT, platelet count, platelet function

If PFA-100™ abnormal, further platelet function If PFA-100™ abnormal, further platelet function tests, including aggregometry and vWF testing, tests, including aggregometry and vWF testing, will be required for diagnosis. will be required for diagnosis.

Results < 5 minutes; $ 10 - $20 depending on Results < 5 minutes; $ 10 - $20 depending on results..results..

CONCLUSIONS:CONCLUSIONS:

Abundant evidence has been accumulated Abundant evidence has been accumulated that the bleeding time is not reliable as a that the bleeding time is not reliable as a screening test for perioperative bleedingscreening test for perioperative bleeding ..

Most non-military hospitals stopped doing Most non-military hospitals stopped doing the test 10 years ago!the test 10 years ago!

REFERENCESREFERENCES

Burns ER, Lawrence C. Bleeding Time: A Guide to its Diagnostic and Clinical Utility. Arch Pathol Lab Med, 1989;113:1219-1224.

Gewirtz AS, Miller ML, Keys TF. The Clinical Usefulness of the Preoperative Bleeding Time. Arch Pathol lab Med, 1996;120:353-356.

Peterson P et al: The Preoperative Bleeding Time Test Lacks Clinical Benefit. Arch Surg, 1998;133:134-139.