Rationale and Comments

The 1989 Medical Necessity Project of the Blue Cross and Blue Shield Association, endorsed by the American College of Physicians, found that at least 70% of prothrombin time and partial thromboplastin time tests were not clinically indicated. Subsequently, nine observational studies, including three prospective trials, reported that prothrombin time and partial thromboplastin time positive predictive values for bleeding complications ranged from 0.03 to 0.22, whereas computed 95% confidence intervals for each assay generates a 2.5% false-positive rate. A review of 27,737 prothrombin time and partial thromboplastin time results over two decades showed that only 8% of prothrombin times and partial thromboplastin times were clinically indicated based on current or prior patient history of bleeding. A study of general hospital unregulated coagulation screening requests produced few abnormal results with no evidence that they were associated with an increased bleeding risk. In this study, all bleeding cases could be attributed to an underlying condition. The risk of intraoperative bleeding is best predicted from a careful history that includes a questionnaire-based bleeding assessment test.

Sponsoring Organizations

• American Society for Clinical Laboratory Science

Sources

• Prospective cohort studies

Disciplines

• Hematologic
• Surgical

References

• Amukele TK, Baird GS, Chandler L. Reducing the use of coagulation test panels. Blood Coagul Fibrinolysis. 2011;22:688-695.
  
• Asaf T, Reuveni H, Yermiahu T, et. al. The need for routine pre-operative coagulation screening tests (prothrombin PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy. Int J Pediatr Otorhinolaryngol. 2001;61(3):217-222.
  
• Baker R. Pre-operative hemostatic assessment and management. Transfus Apher Sci. 2002;27:45-53.
  
• Chee YL, Crawford JC, Watson HG, et al. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008;140:496-504.
  
• Cosmi B, Alatri A, Cattaneo M, et al.; Italian Society for Haemostasis and Thrombosis. Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res. 2009;124(5):e6-e12.
  
• Houry S, Georgeac C, Hay JM, et. al. A prospective multicenter evaluation of preoperative hemostatic screening tests. The French Associations for Surgical Research. Am J Surg 1995;170:19-23.
  
• Kolscielny J, Ziemer S, Radtke H, et.al. A practical concept for preoperative identification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost. 2004;10(3):195-204.
  
• McHugh J, Holt C, O'Keeffe D. An assessment of the utility of unselected coagulation screening in general hospital practice. Blood Coagul Fibrinolysis. 2011;22(2):106-109.
  
• Mozes B, Lubin D, Modan B, et al. Evaluation of an intervention aimed at reducing inappropriate use of preoperative blood coagulation tests. Arch Intern Med. 1989;149(8):1836-1838.
  
• Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review. Transfusion. 2005;45(9):1413-1425.
  
• Wieland A, Belden L, Cunningham M. Preoperative coagulation screening for adenotonsillectomy: a review and comparison of current physician practices. Otolaryngol Head Neck Surg. 2009;140(4):542-547.