Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan

Medical History and Preoperative Coagulation Profile as Predictors of Outcomes in Elective Spinal Surgery: A Meta-Analysis

BACKGROUND

In patients with unremarkable medical history, comprehensive preoperative hemostasis screening in elective neurosurgery remains debated. Comprehensive medical history has shown to be noninferior to coagulation profile to evaluate surgical outcomes. This study aims to evaluate the predictiveness of preoperative coagulation screening and medical history for surgical outcomes.

METHODS

Databases were searched until April 2023 for observational cohort studies that reported preoperative hemostasis screening and clinical history prior to elective neurosurgical procedures. Outcomes of interest included postoperative transfusion, mortality, and complications. Pooled relative risk ratios (RRs) were analyzed using random-effects models.

RESULTS

Out of 604 studies, 3 cohort studies met our inclusion criteria, adding a patient population of 83,076. Prolonged partial thromboplastin time (PTT; RR=1.42, 95% confidence interval [CI] =1.14, 1.77, P=0.002), elevated international normalized ratio (INR; RR=2.01, 95% CI=1.14, 3.55, P=0.02), low platelet count (RR=1.58, 95% CI=1.34, 1.86, P<0.00001), and positive bleeding history (RR=2.14, 95% CI=1.16, 3.93, P=0.01) were associated with postoperative transfusion risk. High PTT (RR=2.42, 95% CI=1.24, 4.73, P=0.010), High INR (RR=8.15, 95% CI=5.97, 11.13; P<0.00001), low platelet count (RR=4.89, 95% CI=3.73, 6.41, P<0.00001), and bleeding history (RR=7.59, 95% CI=5.84, 9.86, P<0.00001) were predictive of mortality. Prolonged PTT (RR=1.53, 95% CI=1.25, 1.86, P=<0.0001), a high INR (RR=3.41, 95% CI=2.63, 4.42, P=< 0.00001), low platelets (RR=1.63, 95% CI=1.40, 1.90, P=<0.00001), and medical history (RR=2.15, 95% CI=1.71, 2.71, P=<0.00001) were predictive of complications.

CONCLUSIONS

Medical history was a noninferior predictor to coagulation profile for postoperative transfusion, mortality, and complications. However, our findings are mostly representative of elective spinal procedures. Cost-effective alternatives should be explored to promote affordable patient care in patients with unremarkable history.

The role of extended coagulation screening in adult cranial neurosurgery

Introduction

Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality.

Research question

We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage.

Methods

A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage.

Results

The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p ​= ​.546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p ​= ​.023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p ​= ​.034). Differences in mean intraoperative blood loss were not significant with 528 ​ml in the study cohort and 486 ​ml in the control cohort (p ​= ​.376).

Conclusion

Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.

Preoperative screening for coagulopathy in elective neurosurgical patients in Wellington Regional Hospital and survey of practice across Australia and New Zealand

It is common practice to perform pre-operative coagulation screening in elective neurosurgery patients, including international normalised ratio (INR) and activated partial thromboplastin time (aPTT). We present a retrospective analysis of 1143 elective neurosurgical patients at Wellington Regional Hospital (WRH) in New Zealand between 2013 and 2017 on whom coagulation screening including INR and aPTT was performed prior to surgery. 21 patients (1.8%) had clinically significant derangements on coagulation profile defined as raised INR or prolonged aPTT. 15 (1.3%) of these patients would be expected to have derangement based on previous history and 6 (0.5%) had unexpected derangements in coagulation profile. Of the 6 patients with unexpected derangements in coagulation profile, all had raised aPTT, none had preoperative correction of coagulopathy and none had bleeding complications or mortality. The cost of coagulation screening across the duration of the study was $68,009 New Zealand Dollars (NZD). A survey of major elective neurosurgery units in Australia and New Zealand found that 85% perform routine laboratory coagulation screening. In the 15% who do not perform laboratory coagulation screening, none use a standardised questionnaire to screen for coagulopathy. We developed a structured questionnaire to assist in detection of coagulopathy in elective neurosurgery patients. Our findings suggest that there is limited value in performing indiscriminate laboratory coagulation screening in patients with no risk factors on history. Despite this, routine laboratory coagulation screening is common practice in Australia and New Zealand. We propose a structured questionnaire to guide laboratory testing and discussions with haematology colleagues.