Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage

Diagnostic Value of the Pediatric Bleeding Questionnaire in Prediction of Bleeding in Minor Surgery

OBJECTIVE

Preoperative coagulation tests have not been shown to be effective in predicting bleeding complications. The Pediatric Bleeding Questionnaire (PBQ) is a proven and sensitive tool for diagnosing children with a predisposition to bleeding. The aim of this study was to evaluate the usefulness of PBQ as a preoperative screening tool for the prediction of bleeding after minor surgical interventions.

METHODS

Preoperative coagulation tests and PBQ were performed in all patients who underwent minor surgery. The postoperative bleeding status was evaluated and then compared with the coagulation tests and PBQ of the patients.

RESULTS

Evaluation was made of a total of 706 patients, comprising 91.2% males and 8.8% females, with a mean age of 4.8 years (median: 4 y, QR: 1 to 7 y). Prolongation in coagulation tests was observed in 131 (18.5%) patients. Repeated tests in 116 patients were within the normal range, and 5 patients received treatment. Postoperative bleeding occurred in 4 (0.5%) patients. The relationship between coagulation tests and postoperative bleeding was not significant. PBQ was found to be ≥2 in 14 patients, but none of these patients had postoperative bleeding. No significant relationship was found between postoperative bleeding status and PBQ ( p :0.77). The sensitivity, specificity, positive predictive, and negative predictive values of PBQ were 0%, 98%, 0%, and 97.4%, respectively.

CONCLUSIONS

The results of this study demonstrated that neither coagulation tests nor PBQ will be sufficient to predict bleeding after minor surgery, that prolongation in coagulation tests does not always indicate a bleeding tendency, and that bleeding history should also be recorded in detail.

The Impact of Surgical Indication on Posttonsillectomy Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the impact of the surgical indication on posttonsillectomy bleed rates.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

A systematic review was performed searching for articles published from the date of inception to July 6, 2022. English language articles describing posttonsillectomy hemorrhage rates in pediatric patients (age ≤ 18) stratified by indication were selected for inclusion. A meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted. All studies were assessed for risk of bias.

RESULTS

A total of 72 articles with 173,970 patients were selected for inclusion. The most common indications were chronic/recurrent tonsillitis (CT/RT), obstructive sleep apnea/sleep-disordered breathing (OSA/SDB), and adenotonsillar hypertrophy (ATH). Posttonsillectomy hemorrhage rates for CT/RT, OSA/SDB, and ATH were 3.57%, 3.69%, and 2.72%, respectively. Patients operated on for a combination of CT/RT and OSA/SDB had a bleed rate of 5.99% which was significantly higher than those operated on for CT/RT alone (Δ2.42%, p = .0006), OSA/SDB alone (Δ2.30%, p = .0016), and ATH alone (Δ3.27%, p < .0001). Additionally, those operated on for a combination of ATH and CT/RT had a hemorrhage rate of 6.93%, significantly higher than those operated on for CT/RT alone (Δ3.36%, p = .0003), OSA/SDB alone (Δ3.01%, p = .0014), and ATH alone (Δ3.98%, p < .0001).

CONCLUSION

Patients operated on for multiple indications had significantly higher rates of posttonsillectomy hemorrhage than those operated on for a single surgical indication. Better documentation of patients with multiple indications would help further characterize the magnitude of the compounding effect described here.

Post-Tonsillectomy Hemorrhage and the Diagnosis of Occult Pediatric Coagulopathies

OBJECTIVES/HYPOTHESIS

The primary objective of this investigation was to determine rates of abnormal coagulation panels and diagnoses of coagulopathies in children with post-tonsillectomy hemorrhage (PTH). Secondary objectives identified patient demographics and hemorrhage event characteristics that correlated with a coagulopathy diagnosis.

STUDY DESIGN

Case series with chart review.

METHODS

Patients requiring operative control of PTH at a tertiary children's hospital between 2015 and 2019 were included. Details of tonsillectomy procedures and hemorrhage events were reviewed along with screening labs for coagulopathy, referrals to hematology and bleeding disorder diagnoses.

RESULTS

There were 250 children included. Mean age was 8.8 years (95% CI: 8.2-9.4) and 53.6% were males. PTH events occurred at a median of postoperative day six (mean: 5.9, 95% CI: 5.4-6.3), and 14.8% occurred within 24 hours of surgery. In this series, 23 patients (9.2%) had a second PTH, and three (1.2%) had a third PTH. Single and multiple PTH patients were similar with respect to age, gender, postoperative day, and technique (P > .05). Screening coagulation panels were obtained on presentation in 67.8% of children with one PTH and abnormally elevated in 38.3%. All children with multiple PTHs had labs drawn with 34.8% having elevated levels. No child with a single PTH was diagnosed with a bleeding disorder. Conversely, 87.0% of children with multiple PTHs saw hematology and three (13.0%) were diagnosed with a bleeding disorder (P < .001).

CONCLUSIONS

Obtaining coagulation panels in pediatric patients presenting with PTH is rarely useful and diagnosing a coagulopathy is uncommon. However, among children with a second PTH, referral to hematology is reasonable as this group has a significantly higher, albeit small, incidence of undiagnosed bleeding disorders.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2069-E2073, 2021.

Risk of post-operative hemorrhage after adenoidectomy and tonsillectomy: Value of the preoperative determination of partial thromboplastin time and prothrombin time

INTRODUCTION

Tonsillectomy and adenoidectomy (T& A) are the most common pediatric surgical procedures performed world-wide. Bleeding remains the most common complication of these procedures with 1-5.7% prevalence.

METHODS

We recruited 1269 patients who were scheduled for either tonsillectomy, adenoidectomy or both. All patients had preoperative CBC, PT, and aPTT ordered. According to the results, patients were labelled as either "abnormal group" or "normal group".

RESULTS

35 patients had abnormal lab results 18 of these patients were diagnosed with coagulation disorders on further laboratory testing.9 of these patients had no pertinent history of bleeding. Even though an association is noted between abnormal lab tests and preoperative history of risk of bleeding, the correlation did not have high sensitivity (28.6%).

CONCLUSION

This study provides evidence that preoperative history can give some information on patients with abnormal coagulation profile but may underestimate the prevalence of such diseases. In addition, patients with abnormal coagulation profile have more risk of postoperative bleeding even after adequate medical treatment perioperative. Thus, identifying these patients will help the clinician in providing the best surgical management with the least morbidity and mortality.

Postoperative Bleeding and Associated Utilization following Tonsillectomy in Children

Objective To assess posttonsillectomy hemorrhage (PTH), associated nonoperative readmissions/revisits, and reoperations in children. Data Sources MEDLINE, EMBASE, and the Cochrane Library. Review Methods Two investigators independently screened studies against predetermined criteria and extracted key data. Investigators independently assessed study risk of bias and the strength of the evidence of the body of literature. We calculated unadjusted pooled estimates of PTH frequency and conducted a Bayesian meta-analysis to estimate frequency of primary and secondary PTH and PTH-associated reoperation and revisits/readmissions by partial and total tonsillectomy and surgical approach. Results In meta-analysis, the frequency of primary and secondary PTH associated with total and partial tonsillectomy was <4% for any technique and with overlapping confidence bounds. Pooled frequencies of PTH were also <5% overall (4.2% for total tonsillectomy, 1.5% for partial tonsillectomy) in comparative studies. Fewer PTH episodes occurred with tonsillectomy for obstructive sleep-disordered breathing than for throat infection. In meta-analysis, frequency of PTH-associated nonoperative revisits/readmission or reoperation ranged from 0.2% to 5.7% for total tonsillectomy and from 0.1% to 3.7% for partial tonsillectomy. At least 4 deaths were reported in case series including 1,778,342 children. Conclusions PTH occurred in roughly 4% of tonsillectomies in studies included in this review. Although studies typically did not report bleeding severity or amount, relatively few episodes of PTH necessitated reoperation for hemostasis. Nonetheless, tonsillectomy is not without risk of harm. Frequency of PTH across techniques was similar; thus, we cannot conclude that a given technique is superior.

Should healthy children who will undergo minor surgery be screened for coagulation disorder?

The objective of this study is to analyze the major causes of abnormal findings seen in the preoperative coagulation tests of asymptomatic pediatric patients and to discuss the usefulness of coagulation tests prior to minor surgery. Among patients who received minor surgery in Kyung Hee University Medical Center from March 2008 to April 2015, a total of 7114 pediatric patients (ages 1-18) were included in our study. Of these, 226 (3.1%) were referred to the pediatrics hematology-oncology department because of abnormal preoperative coagulation tests. A review of the coagulation tests indicate the majority (n = 216, 95.5%) have prolonged activated partial thromboplastin time (aPTT), whereas a smaller number (n = 10, 4.5%) have prolonged prothrombin time international normalized ratio (PT INR). When the coagulation tests were repeated, 136 displayed abnormal findings again. Of these 136 patients, 128 patients underwent mixing tests, and 127 showed results of correction and were composed as follows: normal (n = 83), subnormal (n = 26), factor deficiency (n = 15), and lupus anticoagulant positive (n = 3). Breakdown by factor deficiencies was as follows: (i) factor XII (n = 9), (ii) factor IX (n = 2), (iii) factors XII and IX (n = 1), (iv) factor VIII (n = 1), (v) factor XI (n = 1), (vi) von Willebrand factor (vWF; n = 1), and (vii) factor V (n = 1). Each factor activity range was mild (21%-39%), so no patients received preoperative medications or clotting factors/blood products. Even in the presence of factor deficiencies, bleeding symptoms were mild and postoperative complications did not occur. These results suggest that coagulation tests may not be needed in healthy children and should be reserved for patients with positive bleeding and/or family history.

Our experience with pre-operative haemostatic assessment of paediatric patients undergoing adenotonsillectomy at Federal Medical Centre, Makurdi

BACKGROUND

In 2-4% of all patients requiring adenoidectomy, tonsillectomy or adenotonsillectomy, pre-operative screening tests for coagulation disorders are indicated to detect surgical bleeding complications. However, because of cost effect on the patients, the usefulness of these tests is being challenged. We therefore highlight our experience in paediatric patients undergoing adenoidectomy, tonsillectomy or both in our centre.

PATIENTS AND METHODS

This is a 3½-year analysis of the data of 165 paediatric patients who had adenoidectomy, tonsillectomy or both over the study period. The data collected included age, sex, procedure done and detailed clinical bleeding history.

RESULTS

A total of 165 children had either adenoidectomy or tonsillectomy, or both. There were 76 males and 89 females giving a male to female ratio of 1:1.2. Their ages ranged from 10 months to 18 years. Eighty-five (51.5%) patients had adenotonsillectomy, 48 (29.1%) and 32 (19.4%) had only tonsillectomies and adenoidectomies, respectively. Only 11 (6.7%) families volunteered the history of either prolonged bleeding with minor injury on the skin or occasional slight nose bleeding. Six (3.6%) patients including 3 of the children with positive family history had posttonsillectomy bleed, out of which 4 (66.7%) were moderate whereas the remaining 2 (33.3%) were severe bleeding, which was not statistically significant (P = 0.041). The two cases of severe bleeding had fresh whole blood transfused whereas the rest that had no bleeding issues were discharged home 48 h postoperatively.

CONCLUSION

Our experience in this study suggests that detailed bleeding history is necessary as well as pre-operative haemostatic assessment, if available and affordable for paediatric patients undergoing adenotonsillectomy.

Use and Utility of Hemostatic Screening in Adults Undergoing Elective, Non-Cardiac Surgery

INTRODUCTION

One view of value in medicine is outcome relative to cost of care provided. With respect to operative care, increased attention has been placed on evaluation and optimization of patients prior to undergoing an elective surgery. We examined more than 2 million patients having elective, non-cardiac surgery to assess the incidence and utility of pre-operative hemostatic screening, compared with a composite of history variables that may indicate a propensity for bleeding, to assess several important outcomes of surgery.

MATERIALS & METHODS

We queried the NSQIP database to identify 2,020,533 patients and compared hemostatic tests (PT, aPTT, platelet count) and history covariables indicative of potential for abnormal hemostasis. We compared outcomes across predictor values; used Person's chi-square tests to compare differences, and logistic regression to model outcomes.

RESULTS

Approximately 36% of patients had all three tests pre-operatively while 16% had none of them; 11.2% had a history predictive of potential abnormal bleeding. Outcomes of interest across the cohort included death in 0.7%, unplanned return to the operating room or re-admission within 30 days in 3.8% and 6.2% of patients; 5.3% received a transfusion during or after surgery. Sub-analyses in each of the nine surgical specialties' most common procedures yielded similar results.

CONCLUSION

The limited predictive value of each hemostatic screening test, as well as excess costs associated with them, across a broad spectrum of elective surgeries, suggests that limiting pre-operative testing to a more select group of patients may be reasonable, equally efficacious, efficient, and cost-effective.

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

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.

Utility of Preoperative Hematologic Screening for Pediatric Adenotonsillectomy

We conducted a 3-year retrospective study to examine the results of preoperative hematologic screening, the incidence of postoperative bleeding, and the possible relationship between the two factors in patients who had undergone tonsillectomy with or without adenoidectomy. Our study population was made up of 875 patients—441 boys and 434 girls, aged 2 to 18 years (mean: 7.52 ± 4.25)—who had been treated at our institution from January 2004 through December 2006. In addition to demographic data, we compiled information on each patient's medical and surgical history, personal and family history of abnormal bleeding, indication for tonsillectomy, and preoperative hematologic screening results. The latter included determinations of the prothrombin time, activated partial thromboplastin time, international normalized ratio (INR), and platelet count. A total of 748 patients (85.5%) had normal findings on preoperative hematologic screening, and 127 (14.5%) had at least one abnormality. Postoperatively, hemorrhagic complications occurred in 31 children (3.5%)—in 22 of the 748 patients with normal screening results (2.9%) and in 9 of the 127 with a screening abnormality (7.1%); the difference between the two groups was statistically significant (p = 0.041). The abnormalities in the latter group consisted of an elevated INR but no otherwise identifiable coagulopathy. Another 14 patients with an abnormal screening result (11.0%) were found to have at least one coagulopathy that was newly diagnosed during our preoperative evaluation; they were treated perioperatively, and none bled postoperatively. Of 21 patients who had a personal or family history of abnormal bleeding, 5 (23.8%) were found to have a coagulopathy, but none bled following surgery. In conclusion, we found that preoperative hematologic screening identified patients with undiagnosed coagulopathies, and with appropriate treatment our surgeons were able to prevent some bleeding events in these patients. Our finding that patients with a mildly elevated INR had a higher incidence of postoperative hemorrhage warrants further study.

Use and utility of preoperative hemostatic screening and patient history in adult neurosurgical patients

OBJECT

The utility of preoperative hemostasis screening to predict complications is uncertain. The authors quantified the screening rate in US neurosurgery patients and evaluated the ability of abnormal test results as compared with history-based risk factors to predict hemostasis-related and general outcomes.

METHODS

Eleven thousand eight hundred four adult neurosurgery patients were identified in the 2006-2009 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression modeled the ability of hemostatic tests and patient history to predict outcomes, that is, intra- and postoperative red blood cell [RBC] transfusion, return to the operating room [OR], and 30-day mortality. Sensitivity analyses were conducted using patient subgroups by procedure.

RESULTS

Most patients underwent all 3 hemostatic tests (platelet count, prothrombin time/international normalized ratio [INR], activated partial thromboplastin time), but few had any of the outcomes of interest. The number of screening tests undergone was significantly associated with intraoperative RBC transfusion, a return to the OR, and mortality; an abnormal INR was associated with postoperative RBC transfusion. However, all tests had low sensitivity (0.09-0.2) and platelet count had low specificity (0.04-0.05). The association between patient history and each outcome was approximately the same across all tests, with higher sensitivity but lower specificity. Combining abnormal tests with patient history accounted for 50% of the mortality and 33% of each of the other outcomes.

CONCLUSIONS

This is the first study focused on assessing preoperative hemostasis screening as compared with patient history in a large multicenter sample of adult neurosurgery patients to predict hemostasis-related outcomes. Patient history was as predictive as laboratory testing for all outcomes, with higher sensitivity. Routine laboratory screening appears to have limited utility. Testing limited to neurosurgical patients with a positive history would save an estimated $81,942,000 annually.

The value of routine preoperative testing in the prediction of operative hemorrhage in adenotonsillectomy

Medical records were reviewed to identify subjects who ranged in age from 1 to 18 years and who had undergone tonsillectomy with or without adenoidectomy. Data obtained included patient demographic information, relevant medical history, history of hemorrhage, family history of hemorrhagic disorders, and drug history. Laboratory data obtained included a baseline coagulation screening to determine prothrombin time, activated partial thromboplastin time, and platelet count. Values were classified as within normal limits or as abnormally prolonged according to the local laboratory reference values. The incidence of postoperative hemorrhage in healthy subjects was evaluated, and the correlation between having a medical history of hemorrhage and an abnormal coagulation screen was assessed. We found that the medical history of the patients studied had positive predictive value of 42.8%, and a negative predictive value of 99.1%. The preoperative coagulation screening had a positive predictive value of 50%, and a negative predictive value of 93.6%.

A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children

BACKGROUND

The American Society of Pediatric Otolaryngology recommends pre-operative coagulation testing only when indicated by history or physical exam. Nevertheless, many surgeons test all children scheduled for tonsillectomy and/or adenoidectomy (T&A). Studies of pre-operative screening have had conflicting results. A decision analysis model was constructed to address the costs and health outcome states of pre-operative screening strategies in children.

PROCEDURE

A 14-day Markov model evaluated three strategies: (1) test all children for coagulation disorders; (2) test only those children with a pertinent history; and (3) perform no pre-operative testing. A literature search and a review of national databases estimated probabilities, costs, and utility data. Parameters then were varied widely in sensitivity analyses. Using a societal perspective and a cycle length of 1 day, we compared the strategies based on total costs and quality-adjusted life years (QALYs).

RESULTS

Total costs for the strategies were $3,200 for testing all children, $3,083 for testing only those with a history finding, and $3,077 for not testing. Total utilities were 0.02579, 0.02654, and 0.02659 QALYs, respectively. Cost-effectiveness ratios were most sensitive to variation in the cost of post-operative care and the probability of post-operative bleeding. The strategy of not testing was dominant in all sensitivity analyses.

CONCLUSIONS

Our results demonstrate that not performing preoperative testing is the most cost-effective strategy. This was persistent in sensitivity analyses, indicating that the model was robust. These data may be helpful to institutions and organizations to formulate policies regarding pre-operative coagulation for children without previous diagnoses of bleeding disorders.

Preoperative coagulation screening for adenotonsillectomy: A review and comparison of current physician practices

Objective: To determine the current practice of pediatric otolaryngologists on a national level and general otolaryngologists on a regional level regarding preoperative coagulation screening prior to adenotonsillectomy.

Study design: A five-question survey of members of the American Society of Pediatric Otolaryngology (ASPO) and the Massachusetts Society of Otolaryngology–Head and Neck Surgery (MSO-HNS).

Subjects and methods: Survey results were analyzed to determine current preoperative screening practices relative to awareness of screening recommendations published in the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) 1999 Clinical Indicators Compendium.

Results: The survey response rate was 27 percent (54/190) and 29 percent (76/260) for MSO-HNS and ASPO members, respectively. In patients with no known bleeding risk, 21 percent of respondents continue to obtain coagulation screening including, at a minimum, a partial thromboplastin time and a prothrombin time. MSO-HNS respondents reported ordering more preoperative coagulation studies than did ASPO respondents (35% vs 10%). Interestingly, awareness of the AAO-HNS consensus statement was similar between the two groups and did not impact screening practices.

Conclusions: The survey results indicate a discrepancy between current practice relative to pre-adenotonsillectomy coagulation screening and the recommendations of the AAO-HNS 1999 consensus statement.

Use of a preoperative bleeding questionnaire in pediatric patients who undergo adenotonsillectomy

Objective

To determine the efficacy of a preoperative bleeding questionnaire (POBQ) and coagulation screening in predicting hemorrhage associated with adenotonsillectomy.

Study Design

Retrospective study.

Subjects and Methods

Between January 1998 and December 2003, 7730 tonsillectomy and adenotonsillectomy patients were administered the POBQ preoperatively. Further coagulation screening was based on POBQ responses.

Results

A total of 232 (3.0%) of 7730 had postoperative bleeding; 184 (3.2%) of 5782 patients who had negative questionnaires bled postoperatively compared with 48 (2.5%) of 1948 patients with positive questionnaires ( P = 0.126). Of 1948 patients with positive questionnaires, 141 (7.2%) had abnormal preoperative coagulation screens and 9 (6.4%) of 141 bled; of the 1807 (92.8%) with negative coagulation screens, 39 (2.2%) bled ( P = 0.005).

Conclusion

The POBQ is an effective tool for identifying patients who are at potential risk for post-tonsillectomy bleeding. Patients with both a positive POBQ and coagulation screen had a statistically higher likelihood of postoperative bleeding than other patients. The POBQ allowed the identification of individuals with bleeding disorders to be treated before surgery, likely decreasing the risk of bleeding in these patients.

Frequency of coagulopathies in cases with post-tonsillectomy bleeding

A tonsillectomiát követő legsúlyosabb komplikáció az utóvérzés. Primer post-tonsillectomiás vérzésről akkor beszélünk, ha az a műtétet követően a nem megfelelően ellátott artériák vérzése miatt 24 órán belül fordul elő. Szekunder post-tonsillectomiás vérzés esetében a komplikáció az 1–10. posztoperatív nap egyikén, legnagyobb gyakorisággal az 5–8. napon jelentkezik. A szekunder vérzések rizikófaktorait illetően az irodalom rendkívül ellentmondásos. Célkitűzés: A szerzők azt a kérdést vizsgálták, hogy a rejtett coagulopathiáknak van-e oki szerepe a post-tonsillectomiás vérzésekben, valamint hogy a műtét előtti általános hematológiai szűrésnek van-e létjogosultsága. Módszer: Vizsgálataik során a 2002 és 2004 között a PTE Fül-orr-gégészeti és Fej-nyaksebészeti Klinikájára utóvérzés miatt felvett 115 beteg közül 107 esetben (59 nő, 48 férfi, átlagéletkor 29 év ± 10,9 év) kezdeményeztek utánvizsgálatot a thrombocytaszám, a vérzési idő, a trombinidő (TI), az aktivált parciális tromboplasztinidő (aPTI), a protrombin/INR ráta és a fibrinogénszint meghatározásával. Eredmények: Az utánvizsgálaton 58 beteg vett részt, közülük 28 esetben (49%) észleltünk kóros értékeket. A kóros értékeket mutatók számára javasolt izolált faktormeghatározáson 19 beteg (68%) vett részt, végül 2 betegben, az utánvizsgálaton megjelentek 3,4%-ában igazolták a korábban nem ismeretes, rejtett coagulopathiát (egy esetben izolált VII. faktorszintcsökkenést, egy esetben kombinált VII. és XII. faktorszintcsökkenést). Meglepő, hogy 3, anticoncipienst szedő nőbetegben trombózisra hajlamosító IX. faktorszint-emelkedést diagnosztizáltak. Következtetések: Vizsgálataikból számos gyakorlati következtetés vonható le: 1. a mindenkire kiterjedő szűrés nem tűnik költséghatékonynak; 2. elsősorban gyermekkorban és pozitív családi anamnézis esetében, valamint pozitív fizikális vizsgálat és gyanút keltő preoperatív anamnesztikus adatok (ismételt orrvérzések!) ismeretében a coagulopathia oka lehet az utóvérzésnek; 3. a legérzékenyebb haemostaseologiai paraméter beteganyagukban az aktivált parciális tromboplasztinidő (aPTI) volt (15/28 kóros érték); 4. a coagulopathia az esetek többségében öröklődő betegség, ezért egy beteg diagnosztizálása segíthet a családtagok vérzékenységének felderítésében is; 5. a szekunder utóvérzések döntő többsége bipoláris olló és bipoláris csipesz használata mellett fordult elő; 6. ugyancsak fontos tanulság, hogy a vérzési idő korrekt vizsgálatára csakis az Ivy-módszer a megbízható technika.

The prevalence of bleeding disorders among healthy pediatric patients with abnormal preprocedural coagulation studies

BACKGROUND

We evaluated the prevalence of hemostatic disorders among pediatric patients with abnormal screening coagulation tests.

PROCEDURE

We analyzed 48 consecutive referrals for abnormal prothrombin times, partial thromboplastin times, or closure times obtained as preprocedural screens. Patients were evaluated by uniform diagnostic testing.

RESULTS

Seventeen patients (35%) had an isolated nonspecific inhibitor (NSI). Six patients (12.5%) presented with mildly low factor activity with a concomitant NSI. These deficiencies were of unclear clinical significance. One patient (2%) had a lupus anticoagulant. Only 9 patients (19%) had a possible or true mild bleeding disorder: 5 patients (10%) had isolated low von Willebrand factor levels, 2 patients (4%) had possible type I von Willebrand disease, and 2 (4%) had platelet aggregation disorders. In all patients, personal and family bleeding history had a positive predictive value of 45% for hemostatic disorders.

CONCLUSIONS

The most common diagnosis among the patients referred to us for abnormal preoperative coagulation tests was a NSI, which is not associated with an increased risk of operative bleeding complications. Less than 20% had a possible or true mild bleeding disorder. Although certain bleeding disorders can be occult in children and are associated with perioperative bleeding risks, our study demonstrates the inherent limitations in making a laboratory diagnosis of a bleeding disorder in pediatric patients preoperatively. Our findings contribute to existing doubt about the usefulness of prothrombin times, partial thromboplastin times, and closure times to identify occult bleeding disorders in this population.

Risiko von Blutungen nach Adenotomie und Tonsillektomie

BACKGROUND

Hemorrhage after tonsillectomy and adenoidectomy remains a serious complication. Therefore, routine preoperative coagulation screening, including activated partial thromboplastin time (aPTT), prothrombin time (PT) and platelet count (PLC), are regularly performed, also for medicolegal reasons. In the recently published statement of the German Society of Otorhinolaryngology, Head and Neck Surgery the need for routine preoperative coagulation screening is discussed, but so far no standardized procedure had been established. According to this statement - at least for children - routine preoperative coagulation screening is not mandatory as long as the thorough medical history provides no evidence for a coagulation disorder ( http://www.hno.org/kollegen/gerinnung_te_ae.html ). The present study was undertaken to determine the occurrence of postoperative hemorrhage on the one hand, and the incidence of abnormal preoperative routine coagulation parameters or pathological anamnesis findings on the other.

PATIENTS AND METHODS

In 688 patients, a standardized clinical history was obtained using a questionnaire. Coagulation screening included aPTT, PT, and PLC was also carried out. Bleeding complications were then correlated with anamnesis features and abnormalities in coagulation screening.

RESULTS

In 39 (5.7%) of the 688 patients we found abnormal coagulation values, which were confirmed in repeated analyses. In six of these a detailed analysis revealed occult coagulation disorders requiring correction only in the case of bleeding complications who were previously unknown. Fifteen patients were already known to have a coagulation disorder, and the anamnesis identified no additional patient at risk. Thus, 21 patients with coagulation disorders requiring correction in the case of a bleeding complication underwent surgery. However, only eight (38%) of these showed abnormal routine coagulation parameters. Surgical treatment of postoperative hemorrhage was required in 12 patients, all of whom had normal values for aPTT, PT and PLC.

CONCLUSION

The frequently performed determination of routine coagulation parameters (aPTT, PT, PLC) is not able to reliably identify relevant coagulation disorders or to predict the risk for postoperative hemorrhagic complications after adenoidectomy or tonsillectomy.

Unidentified Coagulation Disorders in Post-Tonsillectomy Hemorrhage

We conducted a retrospective study of 6,966 patients who had undergone tonsillectomy or adenotonsillectomy to evaluate the incidence and clinical features of previously unidentified coagulation disorders in patients who experienced postoperative hemorrhage (n = 201). We found that post-tonsillectomy hemorrhage secondary to unidentified coagulation disorders is extremely rare. However, normal coagulation values and an insignificant history do not rule out coagulation disorders. If diffuse, persistent, and bilateral bleeding is not related to arterial hypertension, dissection technique, or local infection, a rapid and detailed analysis of coagulation factors should be considered.

Adenotonsillectomy in children with von Willebrand's disease: how and when. A case report with review of the literature

The presence of coagulation pathology in children who are candidates for adenotonsillectomy (AT) is a challenge to the otolaryngologist. von Willebrand's disease (vWD) is the most common hereditary coagulopathy and is due to a quantitative and/or qualitative deficiency of von Willebrand's factor (vWF). In recent years, the administration of 1-deamino-8-D-arginine vasopressin (DDAVP) has been recommended as coadjuvant therapy for surgical procedure. This synthetic hormone promotes the release of vWF and factor VIII from endothelial cells. In this report, the authors describe the history of a child with vWD undergoing successful AT after administration of DDAVP. Furthermore, a review of the literature with particular emphasis on the use of DDAVP is made.

Value of preoperative coagulation tests: reappraisal of major noncardiac surgery

In a retrospective case-control review, we evaluated preoperative coagulation testing in patients undergoing major noncardiac operations to determine if routine testing benefits this group of patients. The platelet count (PC), prothrombin time (PT), and activated partial thromboplastin time (aPTT) in all patients undergoing major noncardiac surgery over a 22-month period were reviewed. The review was done both manually and by the computerized hospital information system. Major surgery was defined as procedures usually associated with significant bleeding. For each patient with abnormal results, another two control patients undergoing the same surgery and matched for age and gender were identified. Case and control patients were compared regarding a change in the management plan, use of blood products, blood loss, and bleeding complications by detailed chart review. A total of 828 patients undergoing nine different surgeries were reviewed. The incidence of abnormal PCs was 2.2% [95% confidence interval (CI) 1.2-3.2%] and that of abnormal PT/aPTTs was 2.1% (95% CI 1.1-3.1%). There were only two cases each of thrombocytopenia and prolonged PT/aPTT where the coagulation tests were not indicated clinically. Although (compared to controls) patients with abnormal tests had more changes in their anesthesia plan (36% vs. 2%, p < 0.001) and platelet or fresh frozen plasma transfusions (50% vs. 9%, p < 0.001), blood loss and the incidence of bleeding complications were not different. We conclude that the use of preoperative coagulation tests in patients undergoing major noncardiac surgery should still be guided by clinical assessment. The surgical procedure itself does not constitute an indication for testing.

Excessive post-tonsillectomy hemorrhage requiring ligature of the external carotid artery

Ligature of the external carotid artery (LECA) is the method of choice in patients with excessive post-tonsillectomy hemorrhage. This retrospective study was undertaken to evaluate the incidence, characteristics and warning signs of excessive post-tonsillectomy hemorrhage.

BASIC PROCEDURES

Between January 1988 and December 2000, a total of 25 patients had to be treated by LECA. Tonsillectomy had been previously performed in seven patients at our department (group A) and in 18 patients elsewhere (group B).

MAIN FINDINGS

LECA was performed in most cases 6 (group A) and 11 days (group B) after tonsillectomy. There was one case with lethal outcome. A total of 12 patients (group B) had been operated by two surgeons.

PRINCIPAL CONCLUSIONS

Excessive bleeding following tonsillectomy may occur as delayed bleeding, abrupt and require immediate LECA and blood transfusion. Prior recurrent episodes of bleeding can be a warning sign. Anatomical vascular abnormalities have to be considered. Inpatient policy in these underestimated cases was life-saving.

[Tonsillectomy by electrical dissection: risk factors of postoperative hemorrhage in children]

OBJECTIVE

To identify pre or intraoperative risk factors that could indicate a higher risk for post-tonsillectomy hemorrhage (PTH) in children undergoing electrocautery dissection. SET-UP: Primary referral hospital.

DESIGN

A retrospective study of 163 post-tonsillectomy children comparing 7 cases of PTH with 156 cases with no PTH.

SAMPLE

This study includes children under the age of 18 that underwent tonsillectomy by dissection between 1997 and 2000.

OUTCOME PARAMETERS

Age, sex, height, weight, body mass index, hemoglobin level, hematocrit, platelet count activated partial thromboplastin time (APTT), fibrinogen, ASA index (physical state classification of the American Society of Anesthesiology) and type of hemostasis.

RESULTS

Prevalence of PTH was 4.29% in the cohort sample. The risk of PTH in children following tonsillectomy by electrodissection is significantly increased in patients over 15 years of age (OR = 8.46, p = 0.04) and when ligatures are used for hemostasis (OR = 8.62, p = 0.02). Activated partial thromboplastin time > or = 32 seconds is marginally significant (OR = 7.82, p = 0.05).

CONCLUSIONS

Our findings show that tonsillectomy by electrodissection has an increased risk of bleeding in older children and when ligatures are used for hemostasis.

The need for routine pre-operative coagulation screening tests (prothrombin time PT/partial thromboplastin time PTT) for healthy children undergoing elective tonsillectomy and/or adenoidectomy

In some medical centers, the routine pre-operative evaluation of healthy children undergoing elective tonsillectomy and/or adenoidectomy (T and A) includes coagulation screening tests (PT, prothrombin Time; PTT, partial thromboplastin time; and INR, international normalized ratio). In this retrospective study, we determined whether there is a positive correlation between prolonged PT/PTT/INR tests in healthy children, with no prior medical history of coagulation problems, and bleeding during surgery and/or bleeding in the month following surgery. We reviewed the records of 416 elective T and A surgeries performed at the Soroka University Medical Center in Beer-Sheva, Israel, over the course of 1999. One hundred and twenty-one (29.1%) patients had preoperative prolonged PT values but only four (3.3%) of these patients experienced light bleeding during surgery. Seven (5.8%) of the 121 patients with prolonged PT tests experienced bleeding episodes during the 1st month subsequent to the surgery. Of the 65 (15.6%) patients who had prolonged pre-operative INR values, only three (4.6%) experienced light bleeding during surgery. Two (3.1%) patients with prolonged INR values experienced light bleeding during the 1st month subsequent to surgery. Sixty-one (14.7%) patients had prolonged first preoperative PTT values, only five of whom (8.2%) experienced light bleeding during surgery. Two (3.3%) of the 61 with prolonged PTT values experienced light bleeding during the 1st month subsequent to surgery. We therefore concluded that pre-operative coagulation screening tests provide low sensitivity and low bleeding predictive value. As such, routine coagulation tests before T &A are not indicated unless a medical history of bleeding tendency is suspected.

Post-Tonsillectomy Hemorrhage: Results of a 3-Month Follow-Up

Episodes of post-tonsillectomy hemorrhage are unpredictable and potentially life-threatening. Primary post-tonsillectomy hemorrhage (<24 hr postoperatively) is generally considered to be more common and more serious than secondary hemorrhage (>24 hr). Therefore, recent studies have focused on the control of primary hemorrhage in order to determine the appropriate length of postoperative observation. The issue of follow-up is becoming more important in light of the increasing popularity of outpatient tonsillectomy. We undertook a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage over the short and long term (3 mo). We studied 602 patients, aged 23 months to 89 years (mean: 20.6 yr), who had undergone inpatient tonsillectomy in 1999 and who had been hospitalized for at least 5 days. Our goal was to ascertain the number of episodes of postoperative hemorrhage that required surgical treatment under general anesthesia. We were able to contact 601 of these patients (or their parents) by telephone 3 months postoperatively to inquire about any instances of delayed secondary bleeding. In all, 16 patients (2.7%) had experienced post-tonsillectomy bleeding that required surgically achieved hemostasis under general anesthesia. Of this group, 11 patients (68.8%) had experienced primary hemorrhage and were treated immediately, and five (31.3%) experienced secondary hemorrhage. One patient in the latter group experienced excessive bleeding 38 days postoperatively, which we believe is the latest episode of secondary bleeding reported to date. Based on the findings of this study, we believe that a postoperative follow-up period of 10 days is sufficient to identify all but the most rare cases of post-tonsillectomy hemorrhage.

Post-tonsillectomy bleeding: a meta-analysis

OBJECTIVE/HYPOTHESIS

To reconcile conflicting reports and opinions of the value of preoperative coagulation studies for patients undergoing tonsillectomy.

STUDY DESIGN

Meta-analysis: Articles were identified by MEDLINE search, references from review articles, textbook chapter, and retrieved reports. Independent observers selected prospective trials of patients undergoing tonsillectomy or adenoidectomy and tonsillectomy. Retrospective studies meeting other inclusion and exclusion criteria were included for sensitivity analyses of results.

METHODS

Data were abstracted from studies for an end point of bleeding with normal and abnormal coagulation tests. Four prospective studies met all inclusion and exclusion criteria. These four studies were used in the data synthesis. An additional eight retrospective studies met all other criteria and were used in the sensitivity analysis.

RESULTS

Pooled analysis of 3384 patients revealed a rate of 3.3% (95% confidence interval [CI], 2.5%-4.1%) for post-tonsillectomy bleeding in patients with normal coagulation studies. A rate of 8.7% (95% CI, 1.5%-15.9%) was obtained for bleeding in patients with abnormal coagulation studies. No significant rate difference in post-tonsillectomy bleeding was demonstrated.

CONCLUSION

There is no difference in the rate of post-tonsillectomy bleeding in patients with abnormal coagulation studies as compared with patients with normal coagulation studies obtained preoperatively.

["Usual" morbidity of pediatric tonsillectomy: a study of 126 cases]

Pediatric tonsillectomy is a common procedure in the ENT practice, usually in a Day-surgery basis. The aim of the present work is to further investigate postoperative morbidity to improve both treatment and quality of assistance. 126 children operated in our Day-surgery unit were included in the study, and a questionnaire with items related to postoperative pain, otalgia, halitosis, vomitig, fever and other aspects was filled by their parents or relatives in charge. Significative pain lasting until the third or fourth day was recorded in half of the cases. At the end of the first week most of the children are improved, although only 55% are eating normally. Vomitting, usually the day of the surgery, is described by one third of cases. In our experience, ambulatory tonsillectomy is a safe procedure with low incidence of complications, which are mild. However, the delay in returning to a normal diet and the relative high incidence of vomiting bring into question the inclusion of tonsillectomy in a Day-Surgery program, making necessary to implement treatment protocols to avoid such problems.

Evaluation of posttonsillectomy hemorrhage and risk factors

BACKGROUND

A 13-year retrospective study was undertaken to determine the incidence of posttonsillectomy hemorrhage, to evaluate potential risk factors, and to assess the efficacy and safety of ambulatory tonsillectomy.

METHODS

From January 1985 to December 1997, 4662 patients underwent tonsillectomy at our institution. Ninety patients with posttonsillectomy bleeding were identified. For each patient with posttonsillectomy bleeding, 2 nonbleeding control subjects were selected and matched by age and sex to evaluate potential risk factors.

RESULTS

Age was the only factor found to be statistically significant among the bleeding patients and the control group. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. In our experience, secondary hemorrhage was more common than primary hemorrhage, presenting most frequently on postoperative days 5 to 7.

CONCLUSIONS

The incidence of posttonsillectomy bleeding in this review was 1.93%, and about half (47%) of the patients with posttonsillectomy hemorrhage returned to the operating room for hemorrhage control. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. Patients with posttonsillectomy hemorrhage, regardless of management, had a 12% incidence of subsequent hemorrhage. We found no difference in the incidence of posttonsillectomy bleeding between outpatient and inpatient procedures.

Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics

STUDY OBJECTIVE

To determine the value of clinical history and preoperative coagulation tests.

DESIGN

Prospective, multicenter clinical investigation.

SETTING

Twenty-four centers over a one-year period.

PATIENTS

1,706 children scheduled for tonsillectomy. In 1, 479 out of 1,706 children, studied age was ranged from 9 months to 15 years. Indications for surgery were tonsillar infection 54%, sleep apnea 33%, or both 13%. Surgical dissection was performed in 1, 284 cases (88%) and sluder technique in 172 cases (12%).

MEASUREMENTS AND MAIN RESULTS

Clinical history of bleeding, preoperative coagulation tests, and perioperative bleeding were recorded. Clinical history of bleeding was positive in 13 patients; clinical history cannot predict abnormal coagulation tests. Coagulation tests were abnormal in 57 children (4%). Only 8 patients had disease-induced bleeding; five children had a preoperative correction of the deficiency in factor of coagulation or received desmopressin acetate prior to surgery in the case of von Willebrand's disease. Bleeding that occurred during the intraoperative period was assessed as abnormal by the surgeon in 101 children (7%) and during the postoperative period in 50 children (3%). Univariate analysis showed a relationship between intraoperative bleeding and age (p < 0.001), sluder technique (p < 0. 001), and abnormal preoperative coagulation tests (p < 0.05). Multivariate analysis showed the probability that bleeding was linked to the center where the surgery took place, the technique used, i.e., sluder technique, and the child's age, i.e., the older children.

CONCLUSIONS

Preoperative assessment based on the history of bleeding cannot predict abnormal laboratory tests. Neither the history of bleeding or laboratory tests can predict postoperative bleeding.

Complications of tonsillectomy and adenoidectomy

Adenotonsillectomy is generally safe surgery, but surgeons should be cognizant of potential complications and be prepared to manage them. Postoperative hemorrhage usually responds to local measures or cautery but can be life-threatening. Preoperative screening of coagulation profiles appears unnecessary. Anesthetic risks have declined with modern techniques, but airway risks, aspiration, and pulmonary edema are possible. Nasopharyngeal valving may be altered by velopharyngeal incompetence or nasopharyngeal stenosis. Sore throat, otalgia, fever, dehydration, and uvular edema are more common postoperative complaints. Less common complications include atlantoaxial subluxation, mandible condyle fracture, infection, eustachian tube injury, and psychological trauma. The prevalence, management, and strategies for avoidance of these are discussed.

Value of Preoperative Prothrombin Time/Partial Thromboplastin Time as a Predictor of Postoperative Hemorrhage in Pediatric Patients Undergoing Tonsillectomy

OBJECTIVE: Hemorrhage after tonsillectomy is a potentially lethal complication. Preoperative assessment consisting of prothrombin time (PT) and activated partial thromboplastin time (PTT) has been used to identify patients at risk for hemorrhage after tonsillectomy and adenoidectomy. We sought to assess the value of PT/PTT screening as a predictor of posttonsillectomy hemorrhage.

DESIGN: A retrospective chart review was carried out with a minimum of 1 month follow-up.

SETTING: Tertiary academic referral center.

PATIENTS: Between January 1992 and June 1995, 382 patients undergoing tonsillectomy were examined; 339 patients with a minimum of 1 month follow-up were reviewed for this study.

MAIN OUTCOME MEASURE: Normal and prolonged PT/PTT values were examined. Bleeding in the intraoperative, immediate postoperative, and delayed phases of healing was examined.

RESULTS: Two-hundred and twenty-two patients had normal PT/PTT, 39 had prolonged PT/PTT, and 78 had no preoperative studies performed. Bleeding occurred in 2.7%, 2.6%, and 3.3%, respectively, of patients. Eight patients had positive family histories of bleeding tendencies. One patient (12.5%) with a normal PT/PTT experienced a delayed posttonsillectomy bleed. Of 39 patients with abnormal coagulation studies, 30 were borderline elevations with no repeat studies done; one patient experienced postoperative hemorrhage. Nine abnormal results were repeated; three returned to normal, three remained prolonged but underwent tonsillectomy with no intervention, and three received hematology consultations. One patient had lupus anticoagulant, one had Hageman Factor deficiency, and one was cleared for surgery with no diagnosis. All patients underwent tonsillectomy with no episodes of postoperative bleeding.

CONCLUSIONS: Preoperative PT/PTT provides no additional information than does a bleeding history for the general pediatric population undergoing tonsillectomy. This should only be done in selective cases where warranted by history.

Inadequate pain management and associated morbidity in children at home after tonsillectomy

A telephone interview with the parents of 84 children who underwent tonsillectomy was conducted within 24 hours after discharge from an ambulatory surgery center. Parents were asked to rate the intensity of their child's pain and data were collected on the type, dose, and amount of analgesics administered, and the types of side effects the children experienced. The mean age of the children was 7 years (SD = 2.31), with an equal number of boys and girls. Overall mean pain intensity was 1.42 (SD = 0.71) and the worst pain intensity ranged from 0 to 3 (Mean = 1.93; SD = 0.83). Acetaminophen with codeine was the most common analgesic prescribed and administered. Children received an average of 3 doses in the first 24 hours after surgery. Seventy-seven percent of the parents stated that pain relief from the analgesic was adequate. Of the 23% who did not feel that pain control was adequate, only 7% contacted a physician. The majority of the children experienced restless sleep (62%), behavior changes (75%), and difficulty taking oral fluids because of complaints of pain (56%). Twenty-six percent of the children had one or more episodes of emesis. Our data suggest that children experience a significant amount of pain in the first 24 hours after tonsillectomy and that parents administer analgesics less frequently than the drugs are prescribed. In addition, children experience significant deleterious effects (i.e., poor oral fluid intake, sleep disturbance, behavioral changes, and emesis) associated with the undertreatment of pain, the analgesic administered, or the surgery itself.

The utility of preoperative hemostatic assessment in adenotonsillectomy

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.