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Assessing preoperative bleeding risk using international normalized ratio and activated partial thromboplastin time:
Hassan Rahhal1, Rebecca Sampat2, Brandon Tse3
1Departamento de Clínica Médica, Instituto Central, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Faculdade de Medicina, Universidade de São Caetano do Sul, São Paulo, Brazil.
Insights
Routine preoperative coagulation tests like prothrombin time (PT) and activated partial thromboplastin time (APTT) show weak links to bleeding risk in most surgeries. PT may predict bleeding in liver disease patients undergoing major abdominal surgery.
Area of Science:
- Clinical Pathology
- Surgical Risk Assessment
- Evidence-Based Medicine
Background:
- Prothrombin time (PT) and activated partial thromboplastin time (APTT) are standard preoperative tests for bleeding risk.
- Guidelines on routine coagulation testing show variability, with a trend toward risk-stratified approaches.
- The general utility of these tests as a screening tool is debated.
Conclusions:
- Coagulation test results (PT, APTT) are not consistently linked to bleeding risk in minor and most major elective surgeries.
- Preoperative PT may be associated with bleeding outcomes in patients with advanced liver disease undergoing major abdominal surgery.
- Routine coagulation screening may not be beneficial for most surgical patients.
Background:
The prothrombin time (PT) and activated partial thromboplastin time (APTT) are often considered routine tests in the assessment of perioperative bleeding risk. Physicians continue to order these tests, and major medical societies guidelines exhibit significant heterogeneity regarding the utility of coagulation tests as a general screening tool, despite many advocating for a risk-stratified approach over routine testing.
Objectives:
This study aimed to assess for association between preoperative coagulation tests and bleeding events around elective surgery.
Methods:
We conducted a systematic review of the literature. Three electronic databases were consulted MEDLINE, EMBASE, and EBM Reviews. Randomized trials and observational studies that assessed the predictive accuracy of preprocedural PT and APTT test results for perioperative bleeding were deemed eligible for inclusion. Outcomes included any bleeding events in the postoperative period.
Results:
In total, 100 studies were included in our qualitative synthesis: otolaryngology (n = 15), minor surgeries and procedures (n = 15), neurosurgery (n = 17), orthopedic surgeries (n = 6), cardiac surgeries (n = 16), liver transplantation or hepatectomy (n = 20), general surgery, and other types of major surgery (n = 11). Qualitative synthesis demonstrated a weak or inconsistent association between PT or APTT and bleeding events. Associations were more frequently reported in studies involving patients with cirrhosis and/or neoplastic disease of the liver undergoing liver resection, transplantation, or major abdominal cancer debulking surgery.
Conclusion:
Our findings confirm that coagulation testing results are not consistently associated with bleeding in minor surgeries and nearly all major elective surgeries. However, PT results might be associated with bleeding outcomes in patients with advanced liver disease undergoing major abdominal surgeries.
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