Incorporation of Evidence Based Guidelines on Bleeding Risk Assessment PRIOR to Ent Surgery into Practice: Real Time Experience

Background: In spite of guidelines recommending the no need for coagulation profile prior to ENT surgeries when challenging history of bleeding is negative, yet surgeons still practice it. Cost and delaying surgeries are major issues faced when insignificant abnormalities are found in the coagulation profile results. In 2008, British Committee for Standards of Hematology has published guidelines (1) on assessing the bleeding risk prior to surgeries or invasive procedures, which stated that the indication for sending a coagulation profile is best based on the bleeding history of the patient.

Aim: This study aimed to measure unbiased estimate of hemostatic outcomes in ENT surgeries in relation to coagulation testing.

Methods: All patients who underwent ENT surgeries from three tertiary hospitals during the period from 1^st July 2016 to 1^st January 2017 were enrolled in the study. The retrieved data included gender, age, type of surgery, results of coagulation blood test (if done), other laboratory test results (complete blood count, biochemical profile, etc.), postoperative bleeds, how it was managed, need for blood transfusion and whether the patient required another surgery to stop the bleeding or not. Patients with known bleeding history or previous coagulation derangement were excluded from the study. The primary outcome was post-operative bleeding.

Results: The study included data from 730 patients who underwent ENT surgical procedures. They were 432 males and 298 females. Their mean age was 19.6 + 16.92 year. Out the 730 patients, 372 patients were interviewed for a challenging bleeding history alone (group 1) and 358 were interviewed plus a pre-operative coagulation profile check (Group 2). Total of fourteen patients (1.9 %) developed postoperative bleeding. None of them was due to abnormal bleeding tendency and they didn't require any hemostatic support. Six of them bled early (primary hemorrhage) while at the hospital due to surgical reasons (surgical site bleed that required suturing). Eight patients had delayed postoperative bleeds, after being discharged (due to eating hard food/Trauma). Only total of four patients had major bleeds, requiring surgical intervention.

Conclusion: Despite guidelines recommending not doing coagulation testing prior to surgeries, many local surgeons still consider preoperative coagulation testing as a standard practice to evaluate the patients bleeding risk prior to any surgical procedure. This has resulted in unnecessary delays in surgeries (reaching up to a year in many patients) besides the parents/patients anxiety and additional total cost. We recommend awareness campaigns for surgeons and adhering to guidelines of taking detailed hemostatic history.

Reference:

Chee YL1, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504.

Keywords: Coagulation testing, Bleeding History, Surgery