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European Journal of Anaesthesiology:
doi: 10.1097/EJA.0b013e32835f66cd
Guidelines

Pre-interventional haemostatic assessment: Guidelines from the French Society of Anaesthesia and Intensive Care

Bonhomme, Fanny; Ajzenberg, Nadine; Schved, Jean-François; Molliex, Serge; Samama, Charles-Marc; for the French Anaesthetic and Intensive Care Committee on Evaluation of Routine Preoperative Testing

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Author Information

From the Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland (FB); Department of Haematology, AP-HP, Bichat-Claude Bernard Hospital, Université Paris-Diderot, Sorbonne Paris Cité, INSERM U698, Paris, France (NA); Laboratory of Haematology, CHU Montpellier, University Hospital, Montpellier, France (JFS); Department of Anaesthesiology and Intensive Care Medicine, Centre Hospitalier Universitaire, Saint Etienne, France (SM), and Department of Anaesthesia and Critical Care, Hôtel-Dieu and Cochin University Hospitals, Assistance Publique Hôpitaux de Paris, Paris Descartes University, Paris, France (CMS)

Correspondence to Dr Fanny Bonhomme, Division of Anaesthesiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland Tel: +41 22 372 74 03; fax: +41 22 372 76 90; e-mail: Fanny.Bonhomme@hcuge.ch

Published online 22 February 2013

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Abstract

Recently the French Society of Anaesthesia and Intensive Care (Société Française d’Anesthésie et de Réanimation [SFAR]) issued recommendations for the prescription of routine preoperative testing before a surgical or non-surgical procedure, requiring any type of anaesthesia. Thirty clinical specialists performed a systematic analysis of the literature, and recommendations were then developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. One part of these guidelines is dedicated to haemostatic assessment. The goal of pre-anaesthetic screening for congenital or acquired haemostatic disorders is to prevent perioperative haemorrhagic complications through appropriate medical and surgical management. Preoperative assessment of bleeding risk requires a detailed patient interview to determine any personal or family history of haemorrhagic diathesis, and a physical examination is necessary in order to detect signs of coagulopathy. Laboratory investigation of haemostasis should be prescribed, not systematically, but depending on clinical evaluation and patient history. Standard tests (prothrombin time, activated partial thromboplastin time, platelet count) have a low positive predictive value for bleeding risk in the general population. Patients with no history of haemorrhagic diathesis and no conditions liable to interfere with haemostasis should not undergo pre-interventional haemostasis testing. Conversely, the existence of a positive history or a disease that could interfere with haemostasis should be an indication for clinically appropriate testing.

Index

1. Introduction  143

Standard haemostatic assessment  144

2. Methods  144

3. Results  145

Abnormal test results  153

Modifications to medical management  153

Prediction of bleeding risk  153

Impact of age  153

Impact of ASA score and invasive procedure type  153

Other haemostatic tests  158

4. Discussion and recomendations  158

Recommendation 1  158

Recommendation 2  159

Recommendation 3  159

Recommendation 4  159

Recommendation 5  159

Recommendation 6  159

Recommendation 7  159

5. Conclusion  160

6. References  160

Abbreviations

ACT Activated clotting time

ANAES Agence Nationale d’Accréditation et d’Evaluation en Santé

ANDEM Agence nationale pour le développement de l’évaluation médicale

aPTT Activated partial thromboplastin time

ASA American Society of Anesthesiologists

BCSH British Committee for Standards in Haematology

BT Bleeding time

CI Confidence interval

creat Creatinine

ECG Electrocardiogram

electro Electrolytes

FDP Fibrin degradation products

Fib Fibrinogen

GRADE Grading of Recommendations Assessment, Development and Evaluation

Hb Haemoglobin

HMWK High-molecular-weight kininogen

INR International Normalised Ratio

LR- Negative likelihood ratio

LR+ Positive likelihood ratio

NICE National Institute for Health and Clinical Excellence

NPV Negative predictive value

NS Non specified

OR Odds ratio

PFA-100® Platelet closure time with Platelet Function Analyser

PK Prekallikrein

Plt Platelet count

PPV Positive predictive value

PT Prothrombin time

Se Sensitivity

SFAR Société Française d’Anesthésie et de Réanimation

SISET Societa Italiana per lo Studio dell’Emostasi e della Trombosi

Spe Specificity

VKA Vitamin K antagonists

Xray Chest radiography

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1 Introduction

The use of complementary pre-interventional examinations (prior to surgery, anaesthesia, or any other invasive procedure) is not subject to regulatory standards. The utility and annual cost of routine pre-interventional testing has been widely debated in the literature for several decades, and the French Society of Anaesthesia and Intensive Care (Société Française d’Anesthésie et de Réanimation [SFAR]) has issued recommendations tending towards the rationalisation and limitation of such tests based on existing studies.

The aim of screening for congenital or acquired haemostatic disorders as part of pre-anaesthetic workups is to minimise the risk of perioperative haemorrhagic complications by implementing appropriate medical and surgical management. When requesting haemostatic assessments prior to surgical or other invasive procedures, the objective should be to identify those patients with an increased risk of perioperative bleeding. The commonly first-line requested screening tests of haemostasis known as standard tests include prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count (Plt). These analyses do not specifically address primary haemostasis; hence the time-honoured tradition of adding bleeding time (BT). The limits of BT and its lack of real utility have now been demonstrated in the literature.

Congenital clotting factor deficiencies and platelet function disorders associated with bleeding risk have a low overall prevalence in the general population. The most common are von Willebrand disease (1% overall, of which only 10% have signs of bleeding)1 and haemophilia A (one boy in 5000). Congenital thrombocytopaenia and thrombopathy have a prevalence of roughly one in 30 000. As for rare clotting factor deficiencies (fibrinogen, factors II, V, VII, X, XI, and combined), their prevalence is even lower, somewhere between one in 500 000 and one in 2 000 000 depending on the type of deficiency.2 In asymptomatic patients, the prevalence of these disorders is around one in 40 000.3

Acquired haemostatic disorders are the most common, linked to medication intake in a large majority of cases; 3–5% of the French population is taking antiplatelet agents, and 1% is treated with vitamin K antagonist therapy.

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Standard haemostatic assessment

Activated partial thromboplastin time (aPTT) provides an evaluation of the contact activation pathway (or ‘intrinsic’ pathway) based on concentrations of contact-phase factors (high-molecular-weight kininogen [HMWK], prekallikrein [PK], and factor XII) and factors XI, VIII, and IX. This test measures serum proteins of the common pathway (X, V, II, and fibrinogen). Prolonged aPTT is defined as a ratio of the patient's aPTT to the laboratory's control value of >1.2.

The sensitivity of aPTT depends on the reagent used. Activated partial thromboplastin time is generally used as a screening tool for a deficiency of less than 50% in factors VIII, IX, and XI. It may also be prolonged in the presence of a circulating anticoagulant or deficiencies in factor XII, PK, or HMWK, which do not increase bleeding risk.

Prothrombin time (PT) reflects the main tissue factor coagulation pathway (or ‘extrinsic’ pathway). It is very short (12–13 s in normal individuals), and is used to assess the function of factor VII as well as those factors common to the intrinsic pathway (II, V, X, and fibrinogen).

In some countries, PT may be expressed as a percentage of normal plasma (normal range, 70 to 100%). It has always to be expressed as an International Normalised Ratio (INR) for the monitoring of patients taking vitamin K antagonists (VKA).

An isolated increase of PT can only be due to a factor VII deficiency, which is very rare as an inherited deficiency (1 in 500 000 in the general population).

Bleeding time (BT) yields an overall picture of primary haemostasis in vivo. It is determined mainly via the Ivy method (normal Ivy incision BT <10 min). The old Duke method (earlobe incision) is no longer used. BT is prolonged in cases of severe thrombocytopaenia (platelets <50 × 109 l−1), thrombopathy, deep hypofibrinogenaemia, afibrinogenaemia, dysfibrinogenaemia, von Willebrand disease, severe anaemia (haematocrit <30%) or medication intake interfering with platelet function. BT testing is a delicate procedure that can only be performed by experienced operators, which explains, in part, why this method has fallen out of use.

Platelet closure time, inaccurately referred to as ‘in vitro bleeding time’, measured using the PFA-100® Platelet Function Analyser is a test carried out on citrated whole blood to assess both platelet adhesion and aggregation. Closure time results indicate the time needed to occlude the aperture into a collagen/epinephrine or collagen/adenosine diphosphate-coated membrane under standardised flow conditions. The test is highly sensitive to von Willebrand factor deficiencies, but less so to thrombopathy. As observed with conventional bleeding time, closure time is prolonged in cases of anaemia and thrombocytopaenia, and following the intake of numerous drugs that alter platelet function by inducing acquired thrombopathy.

Platelet count (Plt) is measured using an automated counter, together with red cell and white cell counts, on blood drawn in EDTA anticoagulated samples. In cases of thrombocytopaenia (<150 × 109 l−1), clumping should be investigated by using an automatic cell counter or by evaluation of blood smears. If platelet clumps are identified, the platelet count should be controlled on blood recollected into citrated tube or capillary sample.

These four tests are not sufficient to explore the entire haemostatic system. Some deficiencies with potential bleeding risk disrupt neither aPTT nor PT, as in the case of factor XIII or antiplasmin deficiency, for example. Similarly, thrombocytopathies do not disrupt standard clotting times and may even escape detection by the PFA-100® and BT methods. Moreover, haemostatic function in vivo involves not only the clotting system, but also blood vessels and endothelial cells, and secondarily the fibrinolytic system (clot destruction). In very young infants, the interpretation of biological assessment should take into account the physiological immaturity of the haemostatic system.4 Past the age of one year, children and adults are relatively comparable.5 It should be recalled that test result normality is defined as the range of values of the median 95% of the healthy population with 2.5% above and 2.5% below limits.

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2 Methods

The development of the present guidelines on ‘Routine pre-interventional tests’ was requested and supported by the SFAR, in order to update the French recommendations published in 1998 by the Agence nationale d’accréditation et d’ évaluation en santé (ANAES). The purpose of the guidelines is to develop guidance for clinicians on the use of preoperative investigations. Systematic complementary pre-interventional investigations are those carried out on a routine basis in the absence of clinical signs (anamnestic symptoms) prior to any surgical or non-surgical diagnostic or therapeutic procedure to be performed with or without anaesthesia. Pre-interventional examinations specific to a given procedure or disease are thus excluded.

A recommendations development group consisting of five anaesthesiologists was convened by the SFAR (see Acknowledgments). The task force was divided into eight working groups (cardiac evaluation, respiratory evaluation, haemostatic assessment, haematological and immuno-haematological tests, biochemical examinations, assessment of pregnant women and pregnancy screening, infectious diseases screening, paediatric specificities), composed of three to five physicians (anaesthesiologists, cardiologist, pneumonologist, haematologist, biologists, gynaecologist) in both academic and non-academic practices, from various geographic areas of France (see Acknowledgments). Each working group was responsible for its respective review literature.

Regarding haemostatic assessment, a literature review was carried out using the PubMed database records from 1953 to December 2010, including analysis of the references from the selected articles. The database was searched for prospective and retrospective studies, clinical practice recommendations, consensus conferences, literature reviews and meta-analyses, based on the following key-words: ‘preoperative/pre-operative tests’ or ‘screening tests, routine tests, screening testing’ or ‘hemostasis/haemostasis’ or ‘hemostatic/haemostatic tests’ or ‘coagulation tests’ or ‘activated partial thromboplastin time, PTT, aPTT’ or ‘prothrombin time, PT’ or ‘international normalised ratio, INR’ or ‘bleeding time’ or ‘platelet count’ or ‘PFA-100’ or ‘verify now’ or ‘clinical assessment’ or ‘clinical history’ or ‘preoperative bleeding questionnaire’, plus ‘preoperative evaluation’ or ‘bleeding risk’ or ‘perioperative bleeding’ or ‘haemorrhage/hemorrhage’ or ‘elective surgery, emergency’. For paediatrics in particular, the literature search was performed using the following key-words: ‘children’, ‘paediatric’, ‘newborn’, ‘neonate’, ‘coagulation’, ‘haemostasis’, ‘preoperative’.

Only articles in English or French were analysed. Biological testing prescribed prior to cardiac surgery, pulmonary resection or intracranial surgery were excluded from analysis because such interventions each account for less than 1% of the surgical procedures carried out in France,6 and involve tests determined by surgery- and patient-specific testing strategies. Newborns (0–28 days of life) were also excluded since neonatal anaesthesia is performed exclusively in specialised centres.

Routine laboratory testing for the risk of perioperative thrombo-embolic events has been poorly investigated, and is thus not addressed in this review.

The possibility of establishing recommendations based on patient severity (ASA score) and surgery type was analysed. Minor surgery was defined as not involving loss of major function, no haemorrhagic events and with a limited risk of thrombo-embolic events. Major surgery was defined as displaying one or more of these characteristics. Any surgery matching neither of these two definitions was considered intermediate.

For each standard haemostatic test, the following criteria were evaluated: diagnostic performance (correct identification of abnormalities), therapeutic impact (modification of perioperative management) and prognostic utility/added value (prediction of perioperative bleeding risk). As to peri-interventional haemorrhagic complications and bleeding prediction, sensitivity and specificity referred to the proportions of patients with abnormal or normal results in those presenting or not presenting with any abnormal perioperative bleeding, respectively. Positive predictive value (PPV) and negative predictive value (NPV) were considered to reflect, respectively, the probability of abnormal bleeding after abnormal results and the probability of no haemorrhagic complications after normal results. The prognostic performance of clinical examinations and patient interviews was also analysed, when appropriate data were available, and compared to that of complementary investigations.

The literature analysis and recommendations were developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, which made it possible to differentiate between recommendation level and quality of evidence.7 With the exception of one randomised trial, all the investigations selected for analysis here were of low-grade methodological quality (observational studies or clinical series), but did corroborate one another, thus allowing for some strong recommendations.

Based on this literature analysis, each of the eight working groups proposed recommendations whenever possible. Each recommendation was then evaluated by all the 30 clinical specialists using a scale ranging from one (not agree at all) to nine (totally agree) and validated via the DELPHI method. If all experts (except one) gave a score between seven and nine, a strong agreement was associated with the recommendation; if all experts (except one) gave a score between four and nine with a majority between seven and nine, a weak agreement was associated. Grade 1 recommendations are strong positive (1+ = recommended) or strong negative (1- = not recommended). Grade 2 recommendations are weak positive (2+ = probably recommended or suggested) or weak negative (2- = probably not recommended or not suggested). Finally the guidelines were submitted to a reading group prior to validation. The final guidelines are available online.

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3 Results

The following articles were selected based on the summary or abstract: 48 studies (28 prospective8–35 and 20 retrospective36–55) calculating diagnostic or prognostic performance, two meta-analyses,56,57 six literature reviews,58–63 four international recommendations (ASA,64 BCSH,65 SISET,66 NICE67) and one expert conference.68 The details of these publications are summarised in Tables 1–3. Abnormal result percentages and modifications to medical management for each test, as well as for ‘standard screening tests’ (including PT and aPTT plus platelet count, BT, and fibrinogen, depending on the study considered) are shown in Tables 4–8.

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3.1 Abnormal test results
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The percentage of abnormal test results found in the studies depends on indication (systematic testing or clinically motivated), on the reference values and on the studied patients: <1–29% for PT, <1–16% for aPTT, <1–17% for platelet count, and <1–7% for BT. In selected patients (haemostasis assessment clinically indicated), the percentage of abnormalities was up to 40%. In patients not selected on interviewing and clinical examination, standard haemostatic testing revealed 0.5–16.0% abnormalities. The figures reported here were based on initial observation. Only a few studies provided the percentage of abnormalities confirmed during follow-up testing, when almost half the abnormalities initially detected in asymptomatic patients were not confirmed after analysis of a second sample. In terms of the abnormalities found, some were not associated with increased bleeding risk (such as prolonged aPTT linked to a lupus-type circulating anticoagulant or factor XII deficiency).

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3.2 Modifications to medical management

The frequency of modifications to patient management following detection of an abnormality in systematically requested standard haemostatic testing varied, depending on the study, from 0% to 15%. This counts repetition of tests, additional investigations, time to surgery, special treatments (such as clotting factor substitution), etc. However, corrective interventions (factor substitution or specific treatment) were undertaken in less than 0.6% of cases, and there was no evidence of resulting improvements to patient prognosis (added value).

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3.3 Prediction of bleeding risk

The performance of systematically prescribed standard haemostatic tests in predicting the risk of haemorrhage during a surgical intervention or other invasive procedure was poor, although variable from study to study: sensitivity 0–43%, specificity 64–99%, positive predictive value less than 29%, and negative predictive value 74–99.7% (Table 9).

Table 9
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3.4 Impact of age

Most of the studies reviewed provided no specific details on patient age. Some focused on paediatric populations (patient aged 0–18 years), while others cited only adult subjects of unspecified age, and still others involved a combination of adult and paediatric subjects. The results obtained were therefore insufficient for the stratification of bleeding risk by age. The percentage of abnormalities appeared slightly higher in adult patients than children, but with no apparent difference in the relative number of modifications to medical management. For children, the utility of laboratory investigation of haemostasis in predicting bleeding risk was assessed mainly following tonsillectomy (Table 10). A majority of studies concluded that such systematic testing exhibited low predictive value. Several multivariate analyses did not identify preoperative coagulopathy as a bleeding risk factor.69–73 Only one study explored the utility of systematic biological testing prior to neuraxial anaesthesia, and found no impact on patient management.74

Table 10
Table 10
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3.5 Impact of ASA score and invasive procedure type

Not all studies included details of ASA scoring, and those that did provided no analysis of results in conjunction with the ASA score, thus precluding any ASA-based bleeding risk stratification.

Intervention type should not drive the systematic use of examinations assessing perioperative bleeding risk. Regardless of the type of procedure (general surgery, major surgery, or special surgery such as paediatric tonsillectomy/adenoidectomy), preoperative haemostatic tests remain relatively uninformative and do not aid in the prediction of perioperative bleeding risk.

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3.6 Other haemostatic tests

The authors know of only a few studies on the use of presurgical thrombo-elastography to predict the risk of perioperative bleeding or thrombotic events,33 and most of these are related to cardiac and neurosurgery, making it impossible to evaluate the utility of such testing prior to general surgery. Only one study sought to assess the relevance of the PFA-100® in preoperative detection of primary haemostatic disorders, and concluded that such testing was useful when applied to selected patients.31 The PFA-100® was effective in detecting certain primary haemostatic disorders, namely von Willebrand disease and several platelet disorders, in selected patients. It might therefore be appropriate to offer it to patients whose history includes a primary haemostatic disorder, but not as part of systematic screening.

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4 Discussion and recomendations

Complementary tests are an essential part of any preoperative assessment. Their purpose is to reduce the risks associated with some diagnostic and therapeutic procedures or the anaesthesia they require. Carried out as a routine examination in patients with no history or clinical signs, additional tests are expected to satisfy three main objectives:

to diagnose disease or other conditions not suspected based on patient interviewing or clinical examination, and which may require preoperative treatment or modifications to anaesthetic or surgical management plans;

to serve potentially as a reference for postoperative assessment, or as preparation for the treatment of potential complications;

to support a risk evaluation via their independent predictive value for postoperative complications.

A large majority of the studies concluded that there was no correlation in non-selected patients between abnormalities detected during standard haemostatic assessment and perioperative bleeding. Systematically requested haemostatic tests (PT, aPTT, Plt) did not help to predict perioperative bleeding risk. Such additional testing is costly and delays operations on asymptomatic patients who will not bleed abnormally during surgery (false positives). Worse, it may provide false assurance of non-risk in patients who show normal standard haemostatic test results but in fact suffer from haemostatic disorders that place them at risk of bleeding (false negatives).

The presence or absence of history-based signs of haemorrhagic diathesis should aid in detecting bleeding risk in patients who would otherwise present normal haemostatic tests (such as reducing the number of false negatives), and precluding unnecessary haemostatic tests in patients with no clinical signs of bleeding risk. Physical examination should focus on signs of haemorrhage (petechiae, ecchymoses, bruising and hematomas) as well as jaundice, spleen or liver enlargement (suggesting hepatic disease), and joint hypermobility (indicating a hereditary collagen disease or elastic tissue disorder). Patient interviews designed to identify any personal or family history of haemorrhagic symptoms (spontaneous or provoked) as well as any conditions or treatments liable to interfere with haemostasis remain a simple and easy method of identifying those at risk of bleeding and therefore needing haemostatic assessment.

It goes without saying that patient interviews must be properly conducted. Non-standardised assessments most often lead to an underestimation of bleeding risk. Conversely, it has been shown that excessively vague questionnaires lead to clinical overestimation of bleeding risk and to the use of unnecessary laboratory tests. The symptoms of haemorrhagic diathesis are highly subjective, with up to 25% of healthy patients reporting epistaxis, gingival bleeding, or, in women, ‘significant’ post-partum haemorrhagic events.75

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4.1 Recommendation 1

??

It is recommended that bleeding risk should be assessed based on personal and family history of haemorrhagic diathesis, and based on physical examination. Grade 1+

Multiple haemorrhagic diathesis questionnaires have been developed, but none is validated for the assessment of bleeding risk prior to surgery or other invasive procedures (such as neuraxial anaesthesia).9,55 Validated questionnaires do, however, exist for screening patients (adult or paediatric) for type I von Willebrand disease and other platelet disorders.30,35,76

Prior recommendations, published by the Agence nationale d’accréditation et d’évaluation en santé (ANAES) in 1998 and based on a 1992 report by the Agence nationale pour le développement de l’évaluation médicale (ANDEM), suggested using Watson-Williams’ questionnaire.77 This questionnaire is nonetheless rarely used. A simpler questionnaire could probably be designed based on the various questionnaires already developed to screen for ‘mild bleeding disorders’.78 The following items would have to be included: tendency for prolonged/unusual bleeding (epistaxis, small cuts), tendency to develop ecchymoses/bruising/haematomas, prolonged bleeding after tooth extraction, major bleeding after surgery (especially circumcision or tonsillectomy), family history, and - in women - menorrhagia or postpartum haemorrhage.

There is no validated questionnaire for paediatrics. Certain points can nevertheless be applied to children in particular: cephalo-haematoma or caput succedaneum at birth, umbilical stump bleeding, bleeding at loss of deciduous teeth, epistaxis, easy bruising, puncture-site haematomas, haemorrhagic arthropathy and family history.

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4.2 Recommendation 2

??

A standardised questionnaire should probably be used to screen personal and family history for bleeding diathesis signs. Grade 2+

Such questionnaires are obviously of limited interest in patients for whom personal or family history cannot be obtained, and in young children (typically prior to walking age) with little exposure to haemostatic challenges. Walking-age children are defined as those who have been walking unaided for several months, and may thus already have experienced falls on multiple occasions.

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4.3 Recommendation 3

??

It is recommended that haemostasis testing is not systematically requested in patients whose history and clinical examination results suggest no haemostatic disorders, regardless of ASA score, intervention type and age (with the exception of children who are not yet walking). Grade 1−

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4.4 Recommendation 4

??

Haemostasis testing should not be systematically requested in patients whose history and clinical examination results suggest no haemostatic disorders, regardless of anaesthesia type (general, central, peripheral, or combined), including (for) obstetric procedures. Grade 1−

Haemostatic workups should be performed in cases of liver disease, malabsorption/malnutrition, blood disease or any other pathological state capable of disrupting haemostatic function, as well as in cases of anticoagulant medication (even without bleeding symptoms). Preoperative measurements of aPTT or PT may also prove useful as references for postoperative evaluation (such as PT prior to major hepatic surgery), or as a precaution before certain predictable postoperative therapies (aPTT if unfractionated heparin is indicated postoperatively, platelet count in preparation for heparin treatment, etc.). To date, there are no laboratory tests capable of providing an accurate assessment of bleeding risk in patients on antiplatelet treatment.

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4.5 Recommendation 5

??

It is recommended to get specialist advice in cases where a history of bleeding diathesis suggests disrupted haemostatic function. Grade 1+

Laboratory investigation of haemostasis should be guided by the suspected disease. It should be performed long enough before the date of surgery to allow time for any additional testing that may be judged necessary. Patients with a history of haemorrhagic diathesis suggesting haemostatic disease, but normal standard haemostatic test results, should be referred to specialists. Normal aPTT, PT, and Plt results do not preclude the possibility of haemostatic disease or the risk of perioperative bleeding.

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4.6 Recommendation 6

??

Children who are not yet walking should probably undergo aPTT testing and platelet count so as to rule out certain inherited haemostatic disorders (such as haemophilia). Grade 2+

A family history may prove uninformative or misleading in cases of spontaneously occurring haemophilia. Platelet count should be performed to screen for inherited thrombocytopaenia.

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4.7 Recommendation 7

??

Non-interviewable adults should probably undergo PT and aPTT testing, as well as platelet count, so as to rule out certain inherited or acquired haemostatic disorders. Grade 2+

Summary

Based on comprehensive patient interview and physical examination data, anaesthesiologists should be able to clinically stratify bleeding risk. Haemostatic laboratory testing will thus cease to be systematic, and instead depend on the aforementioned criteria.

In asymptomatic patients with no clinical history of haemostasis disrupting disease, haemostasis testing is unnecessary.

In patients with a history of haemorrhagic diathesis suggesting some pathological state, haemostasis testing should be requested depending on the suspected disease. Frequent skin and cutaneo-mucous bleeding and spontaneous haemorrhage are more indicative of primary haemostatic abnormalities. Internal bleeding, deep-tissue haematoma and haemarthrosis are more indicative of coagulation abnormalities.

Patients treated with antithrombotic agents may be tested to assess the impact of this therapy (if such testing exists).

In patients with known coagulation abnormalities, test results should be checked against usual values (thrombocytopaenia may fluctuate, for example). Additional concomitant abnormalities and the development of inhibitors (in haemophilia cases) should also be ruled out.

Pre-operative measurements of aPTT and PT may also prove useful as references for postoperative evaluation.

It is recommended that bleeding risk should be assessed based on personal and family history of haemorrhagic diathesis. The main unwillingness of physicians to apply this recommendation is that no validated questionnaire is available for anaesthesiologists in daily practice. It would be helpful if such a questionnaire could be developed and validated in the field of anaesthetic assessment. However, due to the low prevalence of congenital haemostatic disorders, the validation of a questionnaire would require a multicentre study with a very large number of inclusions.

These new recommendations are in line with those issued in the United States64 and those issued in the United Kingdom by the National Institute for Health and Clinical Excellence (NICE),67 as well as other English-language recommendations.65 Only the Italian SISET recommendations (Società Italiana per lo Studio dell’Emostasi et della Trombosi) suggest performing systematic haemostasis testing with aPTT, PT and Plt prior to any intervention, even in patients with no bleeding diathesis history.66 This approach is allegedly justified by limited costs. The authors do not agree with this economic argument because the annual cost of systematic preoperative testing is far from low. In France, a screening work-up including PT, aPTT, and Plt costs €13.50, with negligible added value.

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Conclusion

Assessments of perioperative bleeding risk performed during anaesthesia evaluation should be based on detailed patient interviews covering personal and family history, as well as on physical examination. These measures are more sensitive than laboratory investigations in the detection of bleeding risk. Normal standard haemostasis testing results do not preclude the possibility of haemostatic disease and resultant perioperative bleeding risk. Automatically requested haemostasis testing has very little therapeutic impact and cannot predict bleeding risk (no prognostic utility). Only history taking for haemorrhagic diathesis, ideally via a standardised questionnaire, will be systematic. Haemostasis testing should not be systematically used in patients whose history and clinical examination results suggest no haemostatic disorders, regardless of ASA score, intervention type and age (with the exception of children who are not yet walking).

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Acknowledgements

Assistance with the guidelines: Recommendations development group: S Molliex, Saint-Etienne; S Pierre, Toulouse; C Blery, Cavaillon; E Marret, Paris; H Beloeil, Rennes. Task force members. Cardiac evaluation: E Donal, Rennes; D Longrois, Paris; V Piriou, Lyon; B Rozec, Nantes. Respiratory evaluation: CH Marquette, Nice; S Molliex, Saint-Etienne; M Raux, Paris. Haematological tests and immuno-haematological tests: L Augey, Lyon; A François, Paris; A Frisoni, Nancy; E Marret, Paris. Biochemical investigations: H Beloeil, Rennes; A Le Gouez, Clamart; S Pierre, Toulouse. Assessment of pregnant women and pregnancy screening: G Aya, Nîmes; MP Bonnet, Paris; G Ducarme, Clichy; H Keita-Meter, Colombes; N Nathan-Denizot, Limoges. Infectious diseases screening: M Carles, Nice; A Lepape, Lyon; P Montravers, Paris. Paediatric specificities: P Courrèges, Lille; C Dadure, Montpellier; C Lejus, Nantes.

Financial support and sponsorship: This work was supported by the Société Française d’Anesthésie et de Réanimation (SFAR).

Conflicts of interest: JF Schved has received fees from LFB, Novonordisk for participation in review activities. For the remaining authors, none was declared regarding the present work.

Comment from the Editor: We are grateful to Dr Maurizio Solca, acting chairman of the guidelines committee of the European Society of Anaesthesiology (ESA), for valuable comments. The ESA was not involved in the development of these guidelines. CMS is an Associate Editor of the European Journal of Anaesthesiology.

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References

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