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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : -42 مورد

Approach to the initial laboratory evaluation for children presenting with clinically significant bleeding symptoms

Approach to the initial laboratory evaluation for children presenting with clinically significant bleeding symptoms
This figure summarizes our suggested approach to performing laboratory testing and interpreting results in children presenting with clinically significant bleeding symptoms. Bleeding assessment tools such as the PBQ or ISTH-BAT can be used to assess the severity of bleeding symptoms and determine the need for laboratory evaluation. In children, a score of ≥3 (using either tool) is considered a positive screen, indicating that laboratory evaluation is appropriate. For additional details, refer to UpToDate's topic on evaluating bleeding symptoms in children and topics on the specific bleeding disorders.

aPTT: activated partial thromboplastin time; CBC: complete blood count; DIC: disseminated intravascular coagulation; DOAC: direct oral anticoagulant; HMWK: high molecular weight kininogen; HUS: hemolytic uremic syndrome; INR: international normalized ratio; ISTH-BAT: International Society on Thrombosis and Haemostasis bleeding assessment tool; ITP: immune thrombocytopenia; NSAID: non-steroidal anti-inflammatory drug; PBQ: Pediatric Bleeding Questionnaire; PT: prothrombin time; TTP: thrombotic thrombocytopenic purpura; VWD: von Willebrand disease; VWF: von Willebrand factor.

* Examples of peripheral blood smear findings that can help narrow the differential diagnosis include blast forms (indicating a leukemic process), schistocytes (suggesting DIC or other microangiopathic process [eg, TTP, HUS]), giant platelets (suggesting a congenital macrothrombocytopenia syndrome), and platelet clumping (which may indicate pseudothrombocytopenia or may suggest type 2B VWD or platelet-type [pseudo] VWD).

¶ For patients referred for specialist evaluation of abnormal bleeding, most hematologists obtain all 6 tests listed above (CBC with platelet count, peripheral blood smear, PT/INR, aPTT, fibrinogen, and VWD panel) as part of the initial evaluation in most cases. The exception is the well child who presents with acute onset of mucocutaneous bleeding (petechiae, bruising, oral mucosal bleeding). The CBC and peripheral blood smear are the most informative initial tests in such cases since ITP is the most likely diagnosis.

Δ The list of diagnostic possibilities provided in the algorithm includes some of the more common conditions in each category, but it is not exhaustive. Refer to separate UpToDate content on bleeding disorders in children for additional details.

◊ Anemia may be seen in children with considerable ITP-related bleeding (eg, epistaxis or heavy menstrual bleeding). However, anemia out of proportion to blood loss should prompt consideration of alternative diagnoses.

§ These disorders are typically asymptomatic and not associated with clinical bleeding. Patients with these deficiencies are often discovered when an asymptomatic child demonstrates a significantly prolonged aPTT on routine preoperative screening. Although such a deficiency may hold little clinical consequence, it can be important to identify since it provides an explanation for an otherwise puzzling prolonged aPTT.

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