Preoperative assessment of bleeding risk

INTRODUCTION — Preoperative determination of bleeding risk is critical to reducing the risk of excessive surgical bleeding. This topic discusses preoperative assessment of bleeding risk including questions to ask and indications for laboratory testing.

Separate topics discuss:

●General preoperative medical evaluation – (See "Preoperative medical evaluation of the healthy adult patient".)

●Preoperative evaluation for anesthesia – (See "Preoperative evaluation for anesthesia for noncardiac surgery".)

●Perioperative management of anticoagulation – (See "Perioperative management of patients receiving anticoagulants".)

●General perioperative medication management – (See "Perioperative medication management" and "Prevention of perioperative medication errors".)

DETERMINE BLEEDING RISK — Bleeding risk depends on the likelihood of an underlying bleeding disorder and the specific surgical procedure.

Bleeding history

●Elements of the history – The patient's personal bleeding history and family history of bleeding disorders are essential to the preoperative evaluation. Patients should be asked about:

•Nosebleeds

•Oral and dental bleeding

•Skin bleeding

•Whether bleeding occurred with trauma or surgery

•Gastrointestinal, urologic, and menstrual bleeding

•Obstetric bleeding, including postpartum hemorrhage

•Other sites of bleeding (muscle, joints, central nervous system, others)

Children may not have had dental or other procedures, although parents may be aware of an unusual bleeding or bruising tendency. Absence of these "bleeding challenges" can make it more challenging to assess the likelihood of abnormal bleeding in children. (See 'Children' below.)

The severity of past bleeding episodes should be ascertained. For example, any bleeding severe enough to require transfusions, packing, cautery, medications, or surgical exploration is considered more concerning than bleeding that resolved spontaneously or required consultation without interventions.

A history of unexplained, refractory iron deficiency or persistent, unexplained reticulocytosis without hemolysis may suggest an underlying bleeding disorder.

The family history of bleeding disorders is also relevant. Sometimes a formal diagnosis may not have been made, but a first-degree relative may have had significant bleeding. A diagnosis of hemophilia in a male relative is relevant for female patients because they may be a carrier with factor activity low enough to require additional treatments.

●Use of bleeding assessment tool – An easy-to-use bleeding assessment tool (BAT) from the International Society of Thrombosis and Hemostasis (ISTH) that rates the severity of bleeding at these sites is available online and can be completed by a member of the clinical team in a few minutes (ISTH-BAT) [1,2].

An abnormal bleeding history is determined by a positive bleeding score [3]:

•Adult female: ≥6

•Adult male: ≥4

•Child: ≥3

Further study in adult females has shown that scores indicating abnormal bleeding vary by age [4]:

•18 to 30 years: ≥5

•31 to 51 years: ≥6

•52 to 88 years: ≥7

More structured bleeding assessment tools have been developed and widely studied. (See "Approach to the adult with a suspected bleeding disorder", section on 'Bleeding score'.)

The ISTH-BAT was developed to assess for the presence of inherited bleeding disorders, and therefore would not necessarily be useful for patients with acquired conditions such as those caused by medication or concurrent medical problems [5]. Prospective studies using this tool in the preoperative setting are ongoing.

Examination — Physical findings that suggest a potential bleeding disorder include:

●Skin bleeding

•Petechiae (picture 1) or ecchymoses suggests thrombocytopenia or functionally deficient platelets (table 1).

•Telangiectasias may reflect underlying liver disease (spider angiomas, often present on the trunk or face) (picture 2) or hereditary hemorrhagic telangiectasia (HHT, with telangiectasias in the mouth and on the lips) (picture 3). (See "Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis".)

•Hematomas may also be due to factor deficiencies or inhibitors against a clotting factor (table 1).

●Signs of collagen vascular disorders – Some forms of Ehlers-Danlos syndrome can be associated with prolonged bleeding due to an impairment in the structure of the blood vessels. These patients have hyperelasticity of the skin and hyperextendable joints. Other disorders of blood vessel structure associated with clinical bleeding, which may have associated findings on physical examination, include scurvy and Cushing's syndrome (picture 4). (See "Clinical manifestations and diagnosis of Ehlers-Danlos syndromes" and "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder".)

●Signs of liver disease or splenomegaly – Any obvious signs of liver disease (ascites, hepatomegaly) or splenomegaly should be evaluated further. (See "Splenomegaly and other splenic disorders in adults", section on 'How to examine the spleen' and "Clinical manifestations and diagnosis of alcohol-associated fatty liver disease and cirrhosis" and "Assessing surgical risk in patients with liver disease", section on 'Screening for liver disease before surgery'.)

●Sequelae of prior bleeding

•Over time, hemarthroses can lead to joint deformities (table 1). (See "Clinical manifestations and diagnosis of hemophilia", section on 'Late complications'.)

•Resolving bruises may be apparent.

●Acquired von Willebrand syndrome (AVWS) – A heart murmur may indicate aortic stenosis or other cardiac conditions associated with AVWS. (See "Acquired von Willebrand syndrome", section on 'Cardiovascular disease'.)

●Vitamin C deficiency/scurvy – Patients may have gingivitis, loose teeth, perifollicular purpura, and corkscrew hairs. Acquired vitamin C deficiency should be suspected in patients with prior bariatric surgery who present with a new bleeding disorder [6]. (See "Micronutrient deficiencies associated with protein-energy malnutrition in children", section on 'Ascorbic acid' and "Nutritional status in patients with sustained heavy alcohol use", section on 'Vitamin C' and "Overview of water-soluble vitamins", section on 'Vitamin C (ascorbic acid)'.)

Surgical bleeding risk — The table summarizes risk of bleeding with different procedures (table 2).

LABORATORY TESTING

Avoid routine testing in unselected individuals — Routine coagulation testing prior to surgery is generally discouraged due to the low likelihood of finding a bleeding disorder in unselected individuals and the poor predictive value of standard coagulation tests.

●Approach – We reserve laboratory testing for selected individuals and selected procedures with a high risk of bleeding. This includes patients with the following:

•Known bleeding disorder.

•Comorbidity likely to impair hemostasis, such as:

-Active cancer or receiving cancer therapy (see 'Cancer' below)

-Liver disease or excess alcohol intake (see 'Liver disease' below)

-Chronic kidney disease (see 'Kidney disease' below)

•Family history of a bleeding disorder, unless the patient was previously evaluated and determined not to have the disorder. Females who have male relatives with hemophilia may warrant testing for factor activity. (See "Clinical manifestations and diagnosis of hemophilia", section on 'Bleeding in females/carriers' and "Clinical manifestations and diagnosis of hemophilia", section on 'Obstetric considerations'.)

•Receiving an anticoagulant. (See "Perioperative management of patients receiving anticoagulants".)

•Surgery with a high risk of bleeding or a high risk of severe harm should bleeding occur:

-Neurosurgery

-Open cardiac surgical procedures

-Major vascular surgical procedures

Blood tests for hemostasis are routinely available prior to these procedures; they should be closely reviewed and any abnormalities evaluated.

●Guidelines – Our approach is similar to a 2008 systematic review and guideline from the British Committee for Standards in Haematology, which concluded that [7]:

•The positive predictive value for coagulation testing is low.

•Routine coagulation testing should not be performed.

•Bleeding history should be obtained, including specific questions about prior surgical procedures, trauma, antithrombotic medications, and family history.

-If the bleeding history is negative, coagulation testing is not indicated.

-If the bleeding history is positive, further testing is indicated based on the specific findings.

This is also similar to guidelines from other societies, including the American Society of Anesthesiologists, a Choosing Wisely initiative, and a guideline from the Association of Anaesthetists of Great Britain and Ireland, which recommend not using routine preoperative laboratory testing in the absence of a clinical indication. (See "Preoperative evaluation for anesthesia for noncardiac surgery", section on 'Preoperative testing'.)

It differs from a 2009 guideline from the Italian Society for Haemostasis and Thrombosis (SISET), which recommends routine testing of the prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count in all children and adults undergoing surgery or invasive procedures other than endoscopy [8]. The rationale was based on the possibility of identifying a bleeding disorder, especially in children, and the need for baseline testing should complications of the procedure arise.

Guidelines for specific populations propose specific testing, such as in children with cancer [9].

●Evidence from observational studies – Randomized trials in unselected populations comparing routine testing versus no testing are extremely limited. Most evidence comes from small observational studies, often retrospective. These have generally shown poor predictive value of the PT and aPTT for bleeding, as summarized in various guidelines and review articles [7,8,10].

Examples include:

•A 2023 systematic review of nearly 50,000 eye surgeries from four randomized trials and five observational studies found that routine complete blood count (CBC) and coagulation testing did not reduce complications [11].

•Studies of other types of testing that could predict bleeding risk have failed to identify a useful test. Examples of tests evaluated include:

-von Willebrand factor (VWF) antigen [12]

-Thromboelastography (TEG) [13,14]

-Fibrinogen [13]

-Platelet function analyzer (PFA-100) [15] (see "Platelet function testing", section on 'PFA-100')

•The template bleeding time is widely discussed in the context of bleeding risk around surgery. This test is highly unreliable, has largely been abandoned by experts in the field, and has no role in the routine assessment of perioperative bleeding risk.

Testing for people with a suspected bleeding disorder — If the family history, patient history, and/or physical examination suggests a bleeding disorder, appropriate screening tests should be performed.

●Start with PT, aPTT, and platelet count – Generally, people with a suspected bleeding disorder are tested with coagulation studies (PT and aPTT) and CBC with platelet count. (See "Approach to the adult with a suspected bleeding disorder", section on 'Laboratory evaluation' and "Approach to the adult with a suspected bleeding disorder", section on 'Subsequent testing based on initial clinical and laboratory features'.)

●Test for known familial disorders – If there is a known familial bleeding disorder, specific testing for that disorder would be appropriate along with the above testing.

●Follow up abnormal results – Subsequent testing is based on results of the initial testing (table 3). A prolonged aPTT requires further investigation but does not necessarily imply the presence of a bleeding disorder. (See "Approach to the adult with a suspected bleeding disorder", section on 'Positive bleeding history and abnormal screening tests'.)

●Testing for individuals with positive bleeding history and normal initial testing – Some bleeding disorders will have normal PT, aPTT, and platelet count since coagulation factor activity levels generally must be <20 to 40 percent to prolong the PT or aPTT. Individuals with a positive bleeding history and normal initial testing may require specific factor levels, von Willebrand disease (VWD) screening tests, platelet function testing, and/or other tests, depending on the bleeding pattern and family history (table 1).

Evaluation of these patients should be undertaken in concert with an expert clinical center and after careful review of the patient's family history of bleeding. (See "Approach to the adult with a suspected bleeding disorder", section on 'Positive bleeding history and normal initial testing'.)

Supporting evidence comes from observational studies that have found positive bleeding history in up to 19 percent of patients screened by history and physical examination [16,17]. Some of the larger studies that evaluated laboratory testing found abnormal testing in <1 percent of individuals with a negative history [18].

SELECTED PATIENT POPULATIONS

Known bleeding disorder or antithrombotic agent — Preoperative planning should involve the patient's hematologist or other specialist managing their disorder or anticoagulation. Patients with known bleeding disorders will often have written plans for hemostatic management with them in case of severe or unexpected bleeding.

Separate topics discuss general management considerations:

●von Willebrand disease (VWD) – (See "von Willebrand disease (VWD): Treatment of major bleeding and major surgery" and "von Willebrand disease (VWD): Treatment of minor bleeding, use of DDAVP, and routine preventive care".)

●Immune thrombocytopenia (ITP) – (See "Initial treatment of immune thrombocytopenia (ITP) in adults", section on 'Surgery or delivery'.)

●Hemophilia – (See "Treatment of bleeding and perioperative management in hemophilia A and B", section on 'Elective surgery'.)

●Anticoagulants – (See "Perioperative management of patients receiving anticoagulants".)

●Anti-platelet agents – (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)

●Neuraxial anesthesia

•Antithrombotic medications – (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)

•Thrombocytopenia – (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Neuraxial analgesia and low platelets'.)

•Impaired coagulation – (See "Overview of neuraxial anesthesia", section on 'Spinal-epidural hematoma (SEH)'.)

Cancer — For an individual receiving systemic cancer therapy, it is reasonable to check a platelet count. It may also be appropriate to check a PT and aPTT depending on nutritional status and other considerations that would interfere with oral intake and lead to vitamin K deficiency (mucositis, inability to eat, severe diarrhea).

Any active treatment should be reviewed for effects on bleeding risk, and the treating physician consulted. Certain chemotherapeutic and biologic agents should be held perioperatively due to effects on platelet function. Ibrutinib is an example.

Liver disease — (See "Assessing surgical risk in patients with liver disease".)

Kidney disease — (See "Medical management of the dialysis patient undergoing surgery".)

Children — Children with bleeding disorders may have a negative bleeding history because they have not experienced bleeding challenges such as dental extractions, surgeries, circumcision, or menses. (See 'Bleeding history' above.)

As a result, clinicians should be more attentive to the child's history of less severe bleeding and to any family history of bleeding, bleeding disorders, or unexplained iron deficiency.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Preoperative medical evaluation and risk assessment".)

SUMMARY AND RECOMMENDATIONS

●Risk assessment

•Bleeding history – The patient's personal bleeding history and family history of bleeding disorders are essential to the preoperative evaluation. An easy-to-use bleeding assessment tool from the International Society of Thrombosis and Hemostasis (ISTH-BAT) can be completed by a member of the care team in a few minutes. Scores indicating abnormal bleeding are presented above. (See 'Bleeding history' above.)

•Examination – Findings of a possible bleeding disorder include petechiae, ecchymosis or hemosiderin staining, suggestive of prior bleeding; signs of collagen-vascular disorders; hepatomegaly or splenomegaly heart murmurs; and signs of vitamin C deficiency (gingivitis, loose teeth, perifollicular purpura, and corkscrew hairs). (See 'Examination' above.)

•Surgical procedure – The table summarizes bleeding risk for different procedures (table 2). (See 'Surgical bleeding risk' above.)

●Laboratory testing

•Patients with negative bleeding history and family history – Routine coagulation testing prior to surgery is generally discouraged in unselected individuals due to the low likelihood of finding a bleeding disorder and the poor predictive value of standard coagulation tests. We reserve testing for individuals with a personal or family history of a bleeding disorder, comorbidity that impairs hemostasis, receiving an anticoagulant, or undergoing a high-risk procedure (neurosurgery, open cardiac or major vascular procedure). There is no role for the bleeding times. (See 'Avoid routine testing in unselected individuals' above.)

•Patients with suspected bleeding disorder – Testing starts with prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count, with subsequent testing based on abnormal initial results (table 3). Results may be normal in some bleeding disorders, and other testing may be indicated, including factor levels, von Willebrand disease (VWD) screening tests, platelet function tests, and/or others. If there is a known familial disorder, specific testing for that disorder is appropriate. A prolonged aPTT requires further investigation but does not necessarily imply the presence of a bleeding disorder. (See 'Testing for people with a suspected bleeding disorder' above and "Approach to the child with bleeding symptoms" and "Approach to the adult with a suspected bleeding disorder".)

●Special populations

•Known bleeding disorder or anticoagulation – Preoperative planning should involve the patient's hematologist or other specialist managing their disorder or anticoagulation. Patients with known bleeding disorders will often have written plans for hemostatic management with them in case of severe or unexpected bleeding. (See 'Known bleeding disorder or antithrombotic agent' above.)

•Cancer – It is reasonable to check a platelet count, and PT and aPTT may be appropriate. Active treatment should be reviewed for effects on bleeding risk, and the treating physician consulted. Certain agents should be held perioperatively such as ibrutinib. (See 'Cancer' above.)

•Liver or kidney disease – (See "Assessing surgical risk in patients with liver disease" and "Medical management of the dialysis patient undergoing surgery".)

•Children – Children are more challenging to evaluate because they may have had fewer bleeding challenges. (See 'Children' above.)

ACKNOWLEDGMENTS

The UpToDate editorial staff acknowledges Steven Coutre, MD (deceased), who contributed to an earlier version of this topic review.

The UpToDate editorial staff acknowledges Lawrence LK Leung, MD, who contributed to earlier versions of this topic review.