Preoperative coagulation screening prior to tonsillectomy in adults: current practice and recommendations

Abstract

The hypotheses of the study are: (1) a positive history of coagulopathy predicts a higher postoperative haemorrhage risk, (2) a positive laboratory screening for coagulopathy can forecast a higher haemorrhage risk and (3) the haemorrhage risk in patients with known bleeding disorder is elevated. In a multicentre study information on 3,041 tonsillectomies in adults over 9 months, from 1st October 2009 until 30th June 2010, was evaluated. The outcome variables were patient characteristics, postoperative haemorrhage, history of coagulopathy and laboratory screening for coagulopathy. A history of coagulopathy and laboratory screening for coagulopathy were performed in almost all patients (98.6 %, 2,998/3,041). The overall haemorrhage rate was 16 %, including all bleeding episodes after extubation, with 4.8 % returning to theatre. A positive history was reported in 2 % (55/3,041) and a positive laboratory screening in 3 % (94/3,041) of all patients. A positive history is significantly associated with a higher risk of postoperative haemorrhage (31 %, 17/55, p < 0.002) compared to patients with a negative history (16 %, 387/2,497). A positive laboratory for coagulopathy was not significantly associated with an increased haemorrhage risk (20 %, 19/94, p < 0.235) compared to patients with a negative laboratory (16 %, 390/2,249). The haemorrhage risk for adults with a bleeding disorder is twice as high (31 %, 17/55) as for adults without bleeding disorder (16 %, 476/2,973). In conclusion, an adult patient's history of coagulopathy should be taken prior to tonsillectomy as a positive history doubles the haemorrhage risk while a laboratory screening for coagulopathy has no significant power to predict an elevated haemorrhage risk. Bleeding disorders double the risk of postoperative haemorrhage.

Preoperative plasma fibrinogen as a predictive factor for post‐tonsillectomy haemorrhage

“…Coagulation tests, especially thrombin time (TT), partial thromboplastin time (PTT) or activated partial thromboplastin time (APTT) were regularly used to predict PTH. Despite many attempts, none of these parameters showed to a have a potential to predict PTH or RTT, but are still commonly used …”

“…Despite many attempts, none of these parameters showed to a have a potential to predict PTH or RTT, but are still commonly used. 1,6,7 Fibrinogen is one of the most important acute-phase proteins with pivotal functions in acute pro-inflammatory immune reaction and the blood coagulation cascade. 8 Fibrinogen production by hepatocytes is stimulated by pro-inflammatory cytokines, like interleukin-1ß and interleukin-6 and plasma fibrinogen concentrations usually range between 2 and 4 mg/mL.…”

C‐reactive protein and coagulation studies in secondary post‐tonsillectomy haemorrhage – need for routine testing? Our experience in 93 patients

“…However, if there is concern regarding potential clotting disorders or in the presence of a concerning history (spontaneous bruising, family history of bleeding disorders, etc. ), a detailed clotting assessment (coagulation factor and platelet studies in addition to a clotting screen) should be undertaken following discussion with a Haematologist . This is particularly pertinent as the diagnostic yield of a general clotting screen is likely to be very low, even in the presence of coagulation disorders such as Von Willebrand's disease, which will require more detailed haematological tests for diagnosis …”

“…), a detailed clotting assessment (coagulation factor and platelet studies in addition to a clotting screen) should be undertaken following discussion with a Haematologist. 7,8 This is particularly pertinent as the diagnostic yield of a general clotting screen is likely to be very low, even in the presence of coagulation disorders such as Von Willebrand's disease, which will require more detailed haematological tests for diagnosis. 5,6 Similarly, there is currently no evidence relating to the value of routine CRP testing in PTH patients.…”

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

“…Unidentified coagulation disorders are an uncommon reason for PTH [33], [143], and therefore evaluation of a bleeding history is nowadays recommended instead of determination of coagulation values [144], [145], [146], [147], [148], [149], [150], [151], [152], [153], [154], [155]. However, if the clinical findings are suspicious for a coagulation disorder or anemia, exclusion is only possible by taking blood samples.…”