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

Clinical article

Restricted access

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.

Abbreviations used in this paper:ACS = American College of Surgeons; aPTT = activated partial thromboplastin time; INR = international normalized ratio; NSQIP = National Surgical Quality Improvement Program; OR = operating room; PT = prothrombin time; RBC = red blood cell.

Article Information

Address correspondence to: Andreea Seicean, M.P.H., Department of Epidemiology and Biostatistics, Case Western Reserve University, 368 Columbia Road, Bay Village, Ohio 44140. email: aas33@case.edu.

Please include this information when citing this paper: published online February 17, 2012; DOI: 10.3171/2012.1.JNS111760.

© AANS, except where prohibited by US copyright law.

Headings

References

1

Abraham MAhlman JTAnderson CBoudreau AJConnelly J: CPT 2012 Professional Edition Atlanta, GAAmerican Medical Association2010

2

Adams JG JrWeigelt JAPoulos E: Usefulness of preoperative laboratory assessment of patients undergoing elective herniorrhaphy. Arch Surg 127:8018051992

3

American Association of Neurological Surgeons: AANS national neurosurgical procedural statistics survey offers insight into practice management world of neurosurgeons (http://aans.org/Media/Article.aspx?ArticleId=51669) [Accessed January 11 2012]

4

Asaf TReuveni HYermiahu TLeiberman AGurman GPorat A: 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. Int J Pediatr Otorhinolaryngol 61:2172222001

5

Dorman BHSpinale FGBailey MKKratz JMRoy RC: Identification of patients at risk for excessive blood loss during coronary artery bypass surgery: thromboelastography versus coagulation screen. Anesth Analg 76:6947001993

6

Eckman MHErban JKSingh SKKao GS: Screening for the risk for bleeding or thrombosis. Ann Intern Med 138:W15W242003

7

Eisenberg JMClarke JRSussman SA: Prothrombin and partial thromboplastin times as preoperative screening tests. Arch Surg 117:48511982

8

Genecov DGPor YCBarcelo CRSalyer KEMulne AFMorad AB: Preoperative screening for coagulopathy using prothrombin time and partial thromboplastin time in patients requiring primary cranial vault remodeling. Plast Reconstr Surg 116:3893942005

9

Glance LGDick AWMukamel DBFleming FJZollo RAWissler R: Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114:2832922011

10

Houry SGeorgeac CHay JMFingerhut ABoudet MJ: A prospective multicenter evaluation of preoperative hemostatic screening tests. Am J Surg 170:19231995

11

Kang JBrodsky LDanziger IVolk MStanievich J: Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage. Int J Pediatr Otorhinolaryngol 28:1571651994

12

Kaplan EBSheiner LBBoeckmann AJRoizen MFBeal SLCohen SN: The usefulness of preoperative laboratory screening. JAMA 253:357635811985

13

Khuri SF: The NSQIP: a new frontier in surgery. Surgery 138:8378432005

14

Khuri SFHenderson WGDaley JJonasson OJones RSCampbell DA Jr: The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg 204:108911022007

15

Lawrence VAGafni AGross M: The unproven utility of the preoperative urinalysis: economic evaluation. J Clin Epidemiol 42:118511921989

16

Martin JHRosser CJLinebach RFMcCullough DLAssimos DG: Are coagulation studies necessary before percutaneous nephrostomy?. Tech Urol 6:2052072000

17

Munro JBooth ANicholl J: Routine preoperative testing: a systematic review of the evidence. Health Technol Assess 1:iiv1621997

18

Ng KFLai KWTsang SF: Value of preoperative coagulation tests: reappraisal of major noncardiac surgery. World J Surg 26:5155202002

19

Nicoll DMcPhee SJPignone MLu CM: Pocket guide to diagnostic tests 5e. Common Laboratory Tests (http://www.accessmedicine.com/pocketDiagnostic.aspx) [Accessed January 16 2012]

20

Nicoll DMcPhee SJPignone MLu CM: Pocket guide to diagnostic tests 5e. Partial Thromboplastin Time (http://www.accessmedicine.com/pocketDiagnostic.aspx) [Accessed January 16 2012]

21

Nicoll DMcPhee SJPignone MLu CM: Pocket guide to diagnostic tests 5e. Platelet Count (http://www.accessmedicine.com/pocketDiagnostic.aspx) [Accessed January 16 2012]

22

Perez APlanell JBacardaz CHounie AFranci JBrotons C: Value of routine preoperative tests: a multicentre study in four general hospitals. Br J Anaesth 74:2502561995

23

Ramsey GArvan DAStewart SBlumberg N: Do preoperative laboratory tests predict blood transfusion needs in cardiac operations?. J Thorac Cardiovasc Surg 85:5645691983

24

Robbins JARose SD: Partial thromboplastin time as a screening test. Ann Intern Med 90:7967971979

25

Rohrer MJMichelotti MCNahrwold DL: A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 208:5545571988

26

Schoen IBrooks SH: Judgment based on 95 per cent confidence limits: a statistical dilemma involving multitest screening and proficiency testing of multiple specimens. Am J Clin Pathol 53:1901931970

27

Schramm BLeslie KMyles PSHogan CJ: Coagulation studies in preoperative neurosurgical patients. Anaesth Intensive Care 29:3883922001

28

Suchman ALMushlin AI: How well does the activated partial thromboplastin time predict postoperative hemorrhage?. JAMA 256:7507531986

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 41 41 21
Full Text Views 164 164 32
PDF Downloads 91 91 10
EPUB Downloads 0 0 0

PubMed

Google Scholar