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Diagnostic outcome of preoperative coagulation testing in children
11Pediatrics, University of Iowa, Iowa City, Iowa, USA.
Insights
Routine preoperative coagulation tests identify few children with bleeding risks before tonsillectomies. A bleeding history is also limited, suggesting tests are a useful addition to clinical assessment for pediatric surgical patients.
Area of Science:
- Pediatric Hematology
- Surgical Risk Assessment
- Coagulation Disorders
Background:
- The utility of routine coagulation testing versus bleeding history alone for predicting surgical bleeding risk in children undergoing tonsillectomy and adenoidectomy is debated.
- Identifying children with significant coagulation abnormalities preoperatively is crucial for patient safety.
Purpose of the Study:
- To determine the causes of abnormal prothrombin time (PT) and/or activated partial thromboplastin time (aPTT) in pediatric patients undergoing preoperative testing.
- To assess the effectiveness of routine preoperative coagulation testing in identifying children with clinically significant bleeding disorders before surgery.
Main Methods:
- Retrospective chart review of 854 pediatric patients referred for evaluation of abnormal PT/aPTT.
- Analysis of repeat coagulation testing results and bleeding history documentation.
- Identification of specific coagulation abnormalities and their correlation with clinical bleeding history.
Main Results:
- Of 792 analyzed charts, 4% (32 patients) had a potentially significant coagulation abnormality.
- Lupus anticoagulant or presumed lupus anticoagulant was the most common diagnosis (66.2%) among those with initial abnormalities.
- A positive bleeding history was present in 33.8% of patients, but only identified 53.1% of those with significant bleeding disorders.
Conclusions:
- Routine preoperative coagulation testing identifies a small proportion of children at increased risk for surgical bleeding.
- Bleeding history alone is insufficient, identifying only about 60% of children with significant coagulation abnormalities.
- Preoperative coagulation testing can be a valuable adjunct to clinical history in pediatric surgical patients.
Abstract:
The value of routine coagulation testing instead of bleeding history alone in children, to predict bleeding risk prior to tonsillectomy and adenoidectomy has been questioned. Our objectives are to identify the causes of abnormal PT and/or aPTT in these patients, and to determine whether routine preoperative coagulation testing is effective in identifying children with a clinically significant coagulation abnormality prior to undergoing a procedure. In this study, data were extracted by chart review for 854 patients referred to the pediatric hematology service at Stony Brook University for the evaluation of an elevated PT and/or aPTT on preoperative testing. Seven hundred and ninety two of 854 reviewed charts (92.7%) contained sufficient data for analysis. On repeat testing, 393 (49.6%) had a laboratory abnormality identified. A potentially significant coagulation abnormality was identified in 32 of 792 patients (4%). For the remaining 760 patients, the most common diagnosis was a lupus anticoagulant (n = 98, 24.6%) or a "presumed" lupus anticoagulant (n = 166, 41.6%). A positive personal or family bleeding history was documented in 268 patients (268/792 = 33.8%). Of these patients, only 107 (39.9%) had an abnormality identified on further work-up. Seventeen of the 32 patients with clinically significant bleeding disorders identified were found to have a positive bleeding history (17/32 = 53.1%). Routine preoperative coagulation testing identifies only a small number of children at increased risk for surgical bleeding. However, a "positive" bleeding history identifies only 60% of children found to have a clinically significant coagulation abnormality. Routine preoperative coagulation testing may serve as a useful adjunct to clinical history.
