Preoperative Assessment of Hemostasis Or Stop Doing Bleeding Times! Lt Col Lucia E. More United States Air Force

Why Not Bleeding Time? Not reliable as a screening test Not reliable as a screening test Lack reproducibility Lack reproducibility Affected by location of the incision, pressure applied, operator experience, and patient factors such as age, gender, diet, hematocrit, skin laxity, medications, etc. Affected by location of the incision, pressure applied, operator experience, and patient factors such as age, gender, diet, hematocrit, skin laxity, medications, etc.

Why Not Bleeding Time? In the absence of a clinical history of a bleeding disorder, the bleeding time is not a useful predictor of the risk of hemorrhage associated with surgical procedures; In the absence of a clinical history of a bleeding disorder, the bleeding time is not a useful predictor of the risk of hemorrhage associated with surgical procedures; A normal bleeding time does not exclude the possibility of excessive hemorrhage associated with invasive procedures. A normal bleeding time does not exclude the possibility of excessive hemorrhage associated with invasive procedures.

Recommendations for preoperative assessment of hemostasis Careful clinical history including family, dental, obstetric, surgical, traumatic injury, transfusion, and drug history. Careful clinical history including family, dental, obstetric, surgical, traumatic injury, transfusion, and drug history. Physical examination; findings suggestive of a potential bleeding disorder; the presence of petechiae or ecchymoses, telangiectasias, evidence of past hemarthroses (joint deformities in a patient with a positive bleeding history), hematomas etc. Physical examination; findings suggestive of a potential bleeding disorder; the presence of petechiae or ecchymoses, telangiectasias, evidence of past hemarthroses (joint deformities in a patient with a positive bleeding history), hematomas etc. Evaluate specific surgical procedures and their bleeding risks. Evaluate specific surgical procedures and their bleeding risks.

Low 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 dissection There is a limited degree of surgical dissection Local hemostatic measures are likely to be effective Local hemostatic measures are likely to be effective The site does not have local fibrinolysis The site does not have local fibrinolysis i.e. lymph node biopsy, herniorrhaphy, dental extractions i.e. lymph node biopsy, herniorrhaphy, dental extractions

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

So, what should we do instead? Small facilities: Small facilities: – Use flowchart to identify potential bleeders – Refer patient to larger facility/network provider who can evaluate the patient Larger labs: PFA 100 Larger labs: PFA 100

PFA 100 Combined measure of platelet adhesion and aggregation. Combined measure of platelet adhesion and aggregation. Detection of congenital inherited and acquired platelet dysfunction Detection of congenital inherited and acquired platelet dysfunction Screens for von Willebrand disease Screens for von Willebrand disease Assesses the anti-platelet effect of Aspirin Assesses the anti-platelet effect of Aspirin Evaluates platelet dysfunction in children Evaluates platelet dysfunction in children Evaluates platelet dysfunction in multiple clinical settings such as high bleeding risk surgery, high-risk pregnancy and menorrhagia. Evaluates platelet dysfunction in multiple clinical settings such as high bleeding risk surgery, high-risk pregnancy and menorrhagia.

PFA 100 Most common hemostatic disorders can be ruled out w/ PT/APTT, platelet count, platelet function Most common hemostatic disorders can be ruled out w/ PT/APTT, platelet count, platelet function If PFA-100™ abnormal, further platelet function tests, including aggregometry and vWF testing, will be required for diagnosis. If PFA-100™ abnormal, further platelet function tests, including aggregometry and vWF testing, will be required for diagnosis. Results < 5 minutes; $ 10 - $20 depending on results.. Results < 5 minutes; $ 10 - $20 depending on results..

CONCLUSIONS: Abundant evidence has been accumulated that the bleeding time is not reliable as a screening test for perioperative bleeding. Abundant evidence has been accumulated that the bleeding time is not reliable as a screening test for perioperative bleeding. Most non-military hospitals stopped doing the test 10 years ago! Most non-military hospitals stopped doing the test 10 years ago!

REFERENCES Burns ER, Lawrence C. Bleeding Time: A Guide to its Diagnostic and Clinical Utility. Arch Pathol Lab Med, 1989;113: Gewirtz AS, Miller ML, Keys TF. The Clinical Usefulness of the Preoperative Bleeding Time. Arch Pathol lab Med, 1996;120: Peterson P et al: The Preoperative Bleeding Time Test Lacks Clinical Benefit. Arch Surg, 1998;133: