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The utility of preoperative hemostatic assessment in adenotonsillectomy
1Department of Otolaryngology, Head and Neck Surgery, Eastern Virginia Medical School, Norfolk 23507-1912, USA.
Insights
Routine preoperative coagulation tests like PT/PTT are not effective in predicting bleeding for tonsillectomy and adenoidectomy (T and A) patients. Selective screening is recommended over routine testing for cost-effectiveness and better patient outcomes.
Area of Science:
- Otolaryngology
- Pediatric Surgery
- Hematology
Background:
- Tonsillectomy and adenoidectomy (T and A) procedures present hemostatic challenges, particularly in children.
- Routine preoperative coagulation screening is debated for its necessity versus cost-effectiveness in predicting bleeding risk.
- Postoperative hemorrhage following T and A occurs in a small percentage of patients.
Purpose of the Study:
- To evaluate the predictive value of routine preoperative prothrombin time (PT) and activated partial thromboplastin time (PTT) for intraoperative and postoperative bleeding in T and A patients.
- To determine the cost-effectiveness of routine coagulation screening in this pediatric surgical population.
Main Methods:
- Retrospective evaluation of 4373 patients undergoing T and A between 1989 and 1994.
- Analysis of preoperative bleeding histories and laboratory PT/PTT results.
- Correlation of preoperative screening with intraoperative and postoperative bleeding events.
Main Results:
- Only 0.98% (43 out of 4373) of patients experienced postoperative bleeding.
- Preoperative PT and PTT results did not reliably predict intraoperative or postoperative bleeding.
- Laboratory screening demonstrated a low positive predictive value for detecting bleeding disorders or perioperative hemorrhage.
Conclusions:
- Routine preoperative PT/PTT screening is not recommended for patients undergoing T and A.
- Selective use of coagulation screening, based on clinical history, is more appropriate and cost-effective.
- Current screening methods have limited utility in identifying children at risk for bleeding after T and A.
Abstract:
Routine preoperative coagulation screening in patients undergoing tonsillectomy and/or adenoidectomy (T and A) is considered by some to be mandatory. T and A is often the first hemostatic challenge in children; therefore, screening is thought to be useful in predicting patients who may experience postoperative hemorrhage. On the other hand, in today's cost-conscious medical environment, routine screening is considered by some to be an unnecessary added expense. At our institution, among 4373 patients who underwent T and A between 1989 and 1994, 43 returned with postoperative bleeding (0.98%). We retrospectively evaluated the usefulness of prothrombin time (PT) and activated partial thromboplastin time (PTT) in predicting intraoperative and postoperative bleeding. All children had extensive bleeding histories taken; however, preoperative laboratory screening was left to the discretion of the attending physician. Preoperative PT/PTT did not predict intraoperative or postoperative bleeding. In our experience, laboratory screening has a very low positive predictive value in detecting occult bleeding disorders or perioperative hemorrhage; thus, we feel it should be used selectively. Routine preoperative PT/PTT is not recommended to screen T and A patients and does not appear to be cost-effective.