Use and utility of preoperative hemostatic screening and patient history in adult neurosurgical patients.
ABSTRACT 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.
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.
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.
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.
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ABSTRACT: Most studies examining the prognostic value of preoperative coagulation testing are too small to examine the predictive value of routine preoperative coagulation testing in patients having noncardiac surgery. Using data from the American College of Surgeons National Surgical Quality Improvement database, the authors performed a retrospective observational study on 316,644 patients having noncardiac surgery who did not have clinical indications for preoperative coagulation testing. The authors used multivariable logistic regression analysis to explore the association between platelet count abnormalities and red cell transfusion, mortality, and major complications. Thrombocytopenia or thrombocytosis occurred in 1 in 14 patients without clinical indications for preoperative platelet testing. Patients with mild thrombocytopenia (101,000-150,000 µl), moderate-to-severe thrombocytopenia (<100,000 µl), and thrombocytosis (≥450,000 µl) were significantly more likely to be transfused (7.3%, 11.8%, 8.9%, 3.1%) and had significantly higher 30-day mortality rates (1.5%, 2.6%, 0.9%, 0.5%) compared with patients with a normal platelet count. In the multivariable analyses, mild thrombocytopenia (adjusted odds ratio [AOR], 1.28; 95% CI, 1.18-1.39) and moderate-to-severe thrombocytopenia (AOR, 1.76; 95% CI, 1.49-2.08), and thrombocytosis (AOR, 1.44; 95% CI, 1.30-1.60) were associated with increased risk of blood transfusion. Mild thrombocytopenia (AOR, 1.31; 95% CI, 1.11-1.56) and moderate-to-severe thrombocytopenia (AOR, 1.93; 95% CI, 1.43-2.61) were also associated with increased risk of 30-day mortality, whereas thrombocytosis was not (AOR, 0.94; 95% CI, 0.72-1.22). Platelet count abnormalities found in the course of routine preoperative screening are associated with a higher risk of blood transfusion and death.Anesthesiology 07/2013; DOI:10.1097/ALN.0b013e3182a4441f · 6.17 Impact Factor
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ABSTRACT: The true incidence of symptomatic spinal epidural hematoma (SEH) after surgery of the posterior cervical spine and risk factors for its development remain unclear. To determine the 10-year incidence of symptomatic postoperative SEH and to identify risk factors for its development. Retrospective observational study at a Canadian tertiary care spine center. Adult patients undergoing posterior surgery of the cervical spine. Symptomatic postoperative SEH incidence and risk factors for its development. Surgical procedure codes were used to identify study candidates. Using a standard data collection form, two independent reviewers manually searched paper and electronic medical records to extract patient-, treatment- and complication-related data. Time to presentation, clinical findings, method of treatment and intraoperative findings (when relevant) were recorded for patients with an SEH. The overall incidence of symptomatic SEH was calculated and categorical and continuous variables were summarized with percentages and means respectively. Step-wise forward-selection logistic regression analysis was performed to identify risk factors for the development of symptomatic SEH. From January 2002 to December 2011 529 patients (356 men and 173 women, mean age = 56.7 years) were identified for study inclusion. Mean Charlson Comorbidity Index (CCI) was 0.65 (range = 0 - 8). Myelopathy was the most common surgical indication (n=293, 55.4%) with the largest subset of patients undergoing decompression with or without instrumented fusion (n=266, 50.3%). Symptomatic postoperative SEH was diagnosed in 8 patients for an overall incidence of 1.5%. Post-operative NSAID use and an increased CCI were identified as significant predictors of the development of a symptomatic SEH in our study cohort (p = 0.024 and 0.003 respectively). When all other variables remained constant a one-point increase in CCI was associated with 1.6 times higher odds of hematoma development while post-operative NSAID use increased the odds 6.6 times. Symptomatic SEH may occur in up to 1.5% of patients undergoing posterior cervical spine surgery. Patients with a higher level of comorbid disease appear to be at increased risk of development of a symptomatic SEH though avoidance of post-operative NSAIDs may decrease the risk of its development.The spine journal: official journal of the North American Spine Society 12/2013; DOI:10.1016/j.spinee.2013.11.043 · 2.90 Impact Factor
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ABSTRACT: Background: Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications. Methods: This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies. Results: The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period. Conclusion: In preoperative risk assessment, the history and physical examination are the strongest predictors of peri operative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.Deutsches Ärzteblatt International 06/2014; 111(25):437-46. DOI:10.3238/arztebl.2014.0437 · 3.61 Impact Factor