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Usefulness of Routine Coagulation Tests in Healthy Children Undergoing Elective Minor Surgery: a 12-Year
Insights
Routine preoperative coagulation tests in healthy children undergoing minor surgery often yield abnormal results, with factor XII deficiency being common. Selective testing based on bleeding history is recommended.
Area of Science:
- Pediatric Hematology
- Clinical Pathology
- Surgical Hemostasis
Background:
- Routine preoperative coagulation tests (prothrombin time, activated partial thromboplastin time) are used to assess bleeding risk before surgery.
- These tests show low sensitivity and high false-positive rates in minor surgeries, especially in previously healthy children.
- Abnormal results can lead to unnecessary investigations and anxiety, necessitating a review of their utility.
Purpose of the Study:
- To analyze common causes of abnormal preoperative coagulation tests in healthy pediatric patients undergoing elective minor surgery.
- To evaluate the clinical usefulness of routine preoperative coagulation testing in this population.
- To investigate the distribution of factor XII activity in children with prolonged activated partial thromboplastin time.
Main Methods:
- Retrospective review of medical records of 363 pediatric patients (0-18 years) with abnormal preoperative coagulation tests.
- Analysis included repeat testing, mixing studies to identify factor deficiencies or lupus anticoagulants.
- Factor XII activity was assessed in relation to activated partial thromboplastin time results.
Main Results:
- Most patients (96%) had prolonged activated partial thromboplastin time; 8% had prolonged prothrombin time/international normalized ratio.
- Persistent abnormalities were noted in 194 children, with factor deficiency (including factor XII) and lupus anticoagulant identified in 176.
- Factor XII activity showed no significant correlation with activated partial thromboplastin time, and most identified deficiencies were mild.
Conclusions:
- Routine preoperative coagulation tests may not be beneficial for all previously healthy children undergoing minor surgery.
- Selective testing, guided by a positive bleeding history or family history, is suggested.
- Further investigation into the distribution and clinical significance of factor XII activity is warranted.
Background:
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.
Methods:
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.
Results:
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).
Conclusions:
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.
