The Preoperative Bleeding Time Test Lacks Clinical Benefit College of American Pathologists’ and American Society of Clinical Pathologists’ Position Article

ORIGINAL ARTICLE The Preoperative Bleeding Time Test Lacks Clinical Benefit College of American Pathologists’ and American Society of Clinical Pathologists’ Position Article

Powers Peterson, MD; Timothy E. Hayes, MD, DVM; Charles F. Arkin, MD; Edwin G. Bovill, MD; Robert B. Fairweather, MD; William A. Rock, Jr, MD; Douglas A. Triplett, MD; John T. Brandt, MD

he major conclusions of this position article are as follows: (1) In the absence of a history of a bleeding disorder, the bleeding time is not a useful predictor of the risk of hemorrhage associated with surgical procedures. (2) A normal bleeding time does not exclude the possibility of excessive hemorrhage associated with invasive procedures. (3) The bleed- Ting time cannot be used to reliably identify patients who may have recently ingested aspirin or nonsteroidal anti-inflammatory agents or those who have a platelet defect attributable to these drugs. The best preoperative screen to predict bleeding continues to be a carefully conducted clinical history that includes family and previous dental, obstetric, surgical, traumatic injury, transfusion, and drug histories. A history suggesting a possible bleeding disorder may require further evaluation; such an evaluation may include performance of the bleeding time test, as well as a determination of the platelet count, the prothrombin time, and the activated partial thromboplastin time. In the absence of a history of excessive bleeding, the bleeding time fails as a screening test and is, therefore, not indicated as a routine preoperative test. Arch Surg. 1998;133:134-139 Historically, the bleeding time test has been article is to generate a consensus that a rou- used to evaluate the integrity of primary tine preoperative bleeding time test is not hemostasis. The undocumented, but wide- warranted in the patient who does not have spread, assumption is that the bleeding a history of a bleeding disorder. time correlates better with a hemorrhagic tendency in disorders of platelet BACKGROUND INFORMATION function than any other in vitro test. As a consequence, the bleeding time is often de- The bleeding time is an indicator of in vivo termined prior to invasive procedures in primary hemostasis.5 It is prolonged in pa- an attempt to predict the risk of hemor- tients with quantitative or qualitative plate- rhagic complications. Recently, the indi- let disorders or both and in patients with cations for the clinical use of the bleed- abnormalities of vascular wall integrity. ing time have come under closer scrutiny, The bleeding time test assesses the forma- resulting in an increase in the contro- tion of a platelet plug in a skin wound and versy regarding the appropriate use of the reflects complex pathophysiological bleeding time test.1-4 Some of the under- mechanisms that are not completely un- lying issues in this controversy include a derstood. In general, the bleeding time test desire to have a test that accurately pre- is performed by making a small incision dicts the risk of procedure-associated hem- in the skin and then determining how long orrhage, fear of litigation in the event of a it takes for blood flow to cease. major hemorrhage, lack of understand- Historically, the bleeding time test has ing of the limitations of the bleeding time been plagued with problems of reproduc- test, efforts to control rising health care ibility. Numerous modifications have re- costs, and increasingly limited labora- sulted in a more standardized format and tory resources. The goal of this position instrumentation for performing the test. More than 50 years ago, Ivy et al6 advo- The affiliations of the authors appear in the acknowledgment section at the end of cated incising the lateral aspect of the vo- this article. lar surface of the forearm and using a

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©1998 American Medical Association. All rights reserved. Downloaded From: http://archsurg.jamanetwork.com/ on 04/22/2014 sphygmomanometer to elevate capillary pressure and maintain a constant capillary tone, thereby controlling Factors Affecting the Bleeding Time Test a major variable—collapse of the vessel wall. Almost 25 years ago, Mielke et al7 introduced the template tech- Technical variables* Previous test within 4 h nique to address standardization of the length and the Cold applied to adjacent skin depth of the incision. More recently, disposable devices Vigorous exercise based on the approach by Mielke et al have been intro- Variations in cuff pressure duced.8,9 Recent work suggests that these modifica- Excessive wiping of the incision tions to the Ivy technique have not notably improved Excessive anxiety the reproducibility, sensitivity, or specificity of this Direction of the incision 10,11 Age and sex procedure. Despite these attempts to standardize Drugs and medication† technique, the bleeding time test continues to be Aspirin affected by numerous technical variables and clinical Nonsteroidal anti-inflammatory agents conditions (Table).1,5,12-45 Antibiotics There is a relationship between the platelet count ␤-Blockers and the bleeding time that was shown in the classic study Calcium channel blockers of Harker and Slichter.20 Their study of clinically stable, Alcohol ingestion Clinical conditions nonmedicated subjects with pure platelet production de- Congenital‡ fects showed that the bleeding time is normal when the von Willebrand disease platelet count is greater than 100ϫ109/L. However, the Glanzmann thrombasthenia results of their study cannot be generalized because the Bernard-Soulier syndrome patient population they examined is not representative Hermansky-Pudlak syndrome of the patients for whom the bleeding time might be used Platelet-release disorders 1 Other§ to make clinical decisions. There are clinical condi- Uremia tions, such as systemic lupus erythematosus and ure- Liver disorders mia, for which the bleeding time may be prolonged with Chronic myeloproliferative disorders mild thrombocytopenia and for which bleeding prob- Myocardial infarct lems are more likely a reflection of dysfunctional plate- Atherosclerotic cardiovascular disease lets rather than mild thrombocytopenia. Furthermore, Diabetes mellitus Hematocrit there are conditions, such as idiopathic thrombocytope- Paraproteinemias nic purpura, for which the bleeding time may be shorter than would be expected based on the platelet count. Be- *From references 5 and 12 through 18. cause the correlation between the bleeding time and the †From references 23 through 26, 29 through 36, 38 through 40, and 62. platelet count may vary markedly, the bleeding time ‡From Rao.19 should not be used as an estimate of the platelet count. §From references 18, 22 through 28, and 41 through 45.

STUDIES CONCERNING THE PREOPERATIVE other words, the predictive value of a positive test in such USE OF THE BLEEDING TIME TEST a situation is poor. Barber et al47 reviewed 1941 consecu- tive template bleeding times, approximately 95% of which One to 2 million bleeding time procedures are per- were used for a preoperative screen. Only 110 (6%) of formed each year in the United States, making it one of the patients were found to have an abnormal bleeding the most widely used tests of hemostasis.4,46 Most of these time. Eighty-three (75%) of these patients could have been bleeding time tests are probably performed in anticipa- predicted to have an abnormal bleeding time from an ad- tion of surgery or other invasive procedures.47 The bleed- equate clinical history. No obvious cause for the pro- ing time test was introduced in an era when clinical tests longed bleeding time could be found in the other 27 pa- were not scrutinized for their predictive value, quickly tients. Seventeen of these 27 patients later underwent a became established as a “routine” test, and has been pro- second bleeding time test; of these tests, the results for moted as an aid to diagnosis, prognosis, and the moni- 12 were normal, suggesting that most of these long bleed- toring of therapy.1,2 It was assumed to be an effective ing times were false positives due to technical artifact. screening test for congenital disorders of platelet func- There are insufficient data to accurately calculate the tion and a predictor of the risk of bleeding. Despite its sensitivity, specificity, or predictive value of the bleed- widespread clinical use, the bleeding time test is not a ing time regarding perioperative or postoperative hem- good preoperative screening tool for the general popu- orrhage.1,2 Rodgers and Levin1 were able to identify only lation.1,2,47,48 2 published studies with sufficient data to prepare receiver operating characteristic curves. The receiver op- Preoperative Evaluation of Risk of Bleeding erating characteristic curves from these studies indicated that the bleeding time behaved like a noninformative Excessive perioperative bleeding secondary to a preex- test in predicting the risk of bleeding. isting hemorrhagic disorder in a patient with no history Recent reviews have highlighted the inability of the of excessive bleeding is a rare event.1,2,46-48 When a test bleeding time to predict excessive surgical bleeding.1,2,4 is used to screen a low-risk population for an uncom- Multiple studies have found no relationship between the mon event, a positive result is often a false positive. In preoperative bleeding time and the amount of blood loss

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©1998 American Medical Association. All rights reserved. Downloaded From: http://archsurg.jamanetwork.com/ on 04/22/2014 associated with cardiopulmonary surgery.29,49-54 In one tradural space. There are anecdotal cases of spinal sub- double-blind study, the hemostatic integrity of 101 con- dural bleeding in association with the use of antiplatelet secutive patients was evaluated preoperatively by 2 he- medications; however, the preoperative bleeding time has matologists.55 They stratified the patients into 3 groups not been uniformly prolonged in these cases.31,32 Fi- according to the anticipated risk of bleeding; 7 of 8 high- nally, as discussed in the section on “Evaluation of Risk risk patients were classified as such based on a pro- of Bleeding in Patients Taking Aspirin or Nonsteroidal longed bleeding time. Only 2 of the 17 patients who ex- Anti-inflammatory Drugs,” the bleeding time is not a sen- perienced excessive bleeding were prospectively classified sitive test when used to detect the preoperative use of as- as high risk. Two patients died as a result of excessive pirin. Thus, even if there is a slight association between intraoperative hemorrhage; neither had been classified the preoperative use of aspirin and hematoma forma- as high risk. Ferraris and Swanson56 prospectively tion following epidural or spinal anesthesia, the bleed- evaluated the conditions of 129 patients requiring ing time is not an adequate test to identify patients who urgent, unplanned, general surgical procedures. Eight have taken aspirin. of these patients had a prolonged bleeding time preoperatively; none of these 8 patients had excessive bleed- Evaluation of Risk of Bleeding in Patients Taking ing. Handler et al57 observed 38 patients with postop- Aspirin or Nonsteroidal Anti-inflammatory Drugs erative bleeding in a series of 1445 patients undergoing tonsillectomy; there was no difference in the mean The bleeding time is also often misused to identify pa- bleeding time between patients with (5.46-minutes) tients who may have recently ingested a drug, usually as- and without (5.34-minutes) postoperative bleeding. In pirin, known to interfere with platelet function. A his- a subsequent study, they identified 3 of 1603 patients tory of aspirin ingestion has been associated with increased with a long bleeding time prior to tonsillectomy. The blood loss in some clinical settings, including open heart results of a subsequent bleeding time test were abnor- surgery, hip surgery, delivery of a neonate, and gastro- mal in only one of these patients; this patient had von intestinal bleeding.33-36 The clinical desire to identify such Willebrand disease and also had a prolonged activated patients is easy to understand. However, there are 2 ba- partial thromboplastin time.30 sic problems with using the bleeding time for this pur- There is little information regarding the efficacy of pose: (1) the bleeding time is not effective in identifying the bleeding time test in predicting hemorrhagic risk as- such patients and (2) the correlation between bleeding sociated with specialized surgery or other invasive pro- and prolongation of the bleeding time is poor in such cedures. In a prospective study of 139 patients under- patients. going cataract extraction, hyphema developed in 3 (19%) The ingestion of 650 mg of aspirin by volunteers of 16 patients with a prolonged bleeding time compared resulted in a method-dependent mild increase in the with 10 (9.5%) of 105 patients with a normal preopera- bleeding time compared with the individual’s baseline tive bleeding time.58 Although these data suggest a bleeding time.7,26 However, in most of the individuals trend towards an increased risk of hyphema with a long studied, the bleeding time remained within the normal bleeding time, the difference was not statistically signifi- range. In a study of patients receiving long-term aspirin cant. Furthermore, the relationship between aspirin therapy, the mean (±SD) bleeding time in patients re- ingestion and prolongation of the bleeding time was not ceiving 300 mg of aspirin a day was 217± 69 seconds; addressed. Amrein et al59 addressed the effect of periop- in patients receiving 1200 mg of aspirin a day, it was erative administration of aspirin on bleeding in patients 240± 60 seconds; and in patients receiving placebo, it was undergoing hip surgery. While there was a slight 217± 63 seconds.37 In a case-control study, Bashein et al33 increase in blood loss associated with the administra- found that the preoperative bleeding time (±SD) in pa- tion of aspirin, there was no association between the tients taking aspirin within 7 days of open heart surgery preoperative bleeding time and surgical blood loss. was 5.5± 2.2 minutes compared with 4.9± 1.1 minutes Hematoma formation is a rare, but feared, compli- in those not taking aspirin during this period. Although cation of epidural and spinal anesthesia.60-64 The poten- the difference in mean bleeding time was significant, there tial association between the common use of nonsteroi- was too much overlap between the 2 groups to make the dal anti-inflammatory drugs, abnormalities of platelet bleeding time a clinically useful procedure. In a study of function, and hematoma formation have led some to rec- patients requiring unexpected surgery, Ferraris and ommend that a bleeding time test be performed before Swanson56 found that the bleeding time was prolonged epidural anesthesia and that a bleeding time in excess of in only 8 of 22 patients with a history of recent aspirin 10 minutes is a relative contraindication for epidural an- ingestion, documented by suppression of thromboxane 64 esthesia. There are inadequate data to support this con- B2 levels. These studies indicate that the bleeding time clusion.58 Horlocker et al65 found that 39% of the pa- cannot be used to reliably identify patients who have re- tients undergoing spinal or epidural anesthesia were cently received aspirin. exposed to antiplatelet medications in the preoperative Although a history of aspirin ingestion has been as- period. Neurologic complications in association with the sociated with bleeding in patients with some condi- procedure did not develop in any of these patients. Odom tions, there is little evidence that increased blood loss in and Sih66 reported their experience with 1000 cases of such patients can be predicted by the bleeding time. In epidural anesthesia given to patients receiving oral an- their evaluation of the effect of aspirin ingestion on bleed- ticoagulants. They observed no complications that could ing associated with hip surgery, Amrein et al59 found no be related to bleeding or hematoma formation in the ex- correlation between increased bleeding and a bleeding

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©1998 American Medical Association. All rights reserved. Downloaded From: http://archsurg.jamanetwork.com/ on 04/22/2014 time of greater than 10 minutes or an aspirin-induced may be the best indicator of bleeding risk in patients with prolongation of 4 minutes over baseline. As noted pre- uremia.43 Other studies evaluating the relationship be- viously, Ferraris and Swanson56 found no relationship between bleeding of widely varying severity and prolonga- tween surgical bleeding and either preoperative bleed- tion of the bleeding time have failed to establish the use ing time or history of aspirin ingestion in their study of of the bleeding time for the prediction of clinically patients requiring urgent surgical procedures. The rela- severe bleeding in advance of its occurrence.44,45,79,80 In tionship between a history of aspirin ingestion, preop- particular, the study by Eknoyan et al44 showed that a erative bleeding time, and perioperative blood loss has decline in prothrombin consumption was more predic- also been examined in patients undergoing cardiopul- tive of bleeding than any other parameter studied, monary bypass surgery.33,37,39 These studies have shown including the bleeding time. Although some studies that there is an association between a history of aspirin have shown a reasonable correlation between the bleed- ingestion and blood loss but that there is no relation- ing time and “clinical” bleeding (as distinguished from ship between the preoperative bleeding time and blood “surgical” bleeding) in patients with uremia, no con- loss. Finally, O’Laughlin et al40 found that while the skin trolled study has shown that patients with prolonged bleeding time was prolonged after aspirin ingestion, the bleeding times have more clinically significant compli- gastric bleeding time following a gastric biopsy was nor- cations than those with normal bleeding times.1,2,22,43 mal, suggesting that a long skin bleeding time may not Thus, the bleeding time may be useful for monitoring accurately predict the response to vascular injury at other the response to therapy in patients with uremia. How- sites. ever, there is little direct evidence indicating that the Therefore, the most effective method of identifying bleeding time can be used to predict the risk of bleeding patients who may be at risk because of aspirin ingestion in these patients, particularly in a patient undergoing an is the clinical history. The critical period for exposure invasive procedure. to aspirin seems to be approximately 3 days prior to an invasive procedure. A recent study67 documented that CONCLUSIONS platelet function, as measured by thromboxane A2 production and aggregation studies, returned to normal 4 In addressing the issues of concern regarding this labo- days after the cessation of aspirin therapy. Another study68 ratory test, we conclude the following: showed that aspirin-induced prolongation of the bleed- 1. In the absence of a clinical history of a bleeding ing time lasts no longer than 48 hours. The prolonged disorder, the bleeding time is not a useful predictor of bleeding time in patients taking aspirin may be short- the risk of hemorrhage associated with surgical proce- ened after the administration of desmopressin acetate; dures. however, there is no evidence that this translates into de- 2. A normal bleeding time does not exclude the pos- creased perioperative blood loss.41 sibility of excessive hemorrhage associated with invasive procedures. Evaluation of Risk of Bleeding 3. The bleeding time cannot be used to reliably iden- in Patients With Uremia tify patients who may have recently ingested aspirin or nonsteroidal anti-inflammatory agents, or who have a Uremia is a complex metabolic disorder that has delete- platelet defect attributable to these drugs. rious effects on hemostasis. The hemostatic defect asso- The best preoperative screen to predict bleeding con- ciated with uremia is complex and multifactorial and has tinues to be a carefully conducted clinical history, which not yet been fully delineated.69 In recent years, it has be- includes family and previous dental, obstetric, surgical, come evident that a low hematocrit is associated with a traumatic injury, transfusion, and drug histories. A pa- prolonged bleeding time in patients with uremia and that tient with a history suggesting a possible bleeding dis- correction of the hematocrit by transfusion or use of re- order may require further examination. In the absence combinant erythropoietin is associated with normaliza- of a history of excessive bleeding, the bleeding time fails tion of the bleeding time in most patients.70-72 Uncon- as a screening test and is, therefore, not indicated as a trolled studies have suggested that the normalization of routine preoperative test. the bleeding time with increasing hematocrit is associated with a decreased incidence of bleeding.71-74 This ef- This study was supported by the College of American Pa- fect seems to be due to improved interaction between cir- thologists, Northfield, Ill, and by the American Society of culating platelets and the vessel wall, as well as alteration Clinical Pathologists, Chicago, Ill. of a plasma defect associated with uremia.75 From the Departments of Pathology, Cornell Univer- The bleeding time has also been used to assess other sity Medical College, New York, NY (Dr Peterson); Maine forms of intervention in patients with uremia. Several stud- Medical Center, Portland (Dr Hayes); University of Ver- ies have shown that the bleeding time decreases follow- mont College of Medicine, Burlington (Dr Bovill); Dart- ing the intravenous or subcutaneous administration of mouth-Hitchcock Medical Center, Lebanon, NH (Dr Fair- desmopressin acetate within 4 to 6 hours.76 The bleed- weather); University of Mississippi Medical Center, Jackson ing time has also been used to monitor the response to (Dr Rock); Ball Memorial Hospital, Muncie, Ind cryoprecipitate or conjugated estrogens.42,77,78 In all these (Dr Triplett); and Ohio State University College of Medi- reports, there is anecdotal evidence that correction of the cine, Columbus (Dr Brandt); and the Department of Labo- bleeding time was associated with decreased clinical bleed- ratory Medicine, Boston University Medical Center, ing. Indeed, it has been suggested that the bleeding time Boston, Mass (Dr Arkin). Dr Peterson is now with the De-

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IN OTHER AMA JOURNALS

JAMA Electronic Communication With Patients: Evaluation of Distance Medicine Technology E. Andrew Balas, MD, PhD; Farah Jaffrey, MSc; Gilad J. Kuperman, MD, PhD; Suzanne Austin Boren, MHA; Gordon D. Brown, PhD; Francesco Pinciroli, LEE; Joyce A. Mitchell, PhD Objective.— To evaluate controlled evidence on the efficacy of distance medicine technologies in clinical practice and health care outcome. Data Sources.—Systematic electronic database and manual searches (1966-1996) were conducted to identify clinical trial reports on distance medicine applications. Study Selection.—Three eligibility criteria were applied: prospective, contemporaneously controlled clinical trial with ran- dom assignment of the intervention; electronic distance technology application in the intervention group and no similar intervention in the control group; and measurement of the intervention effect on process or outcome of care. Data Extraction.—Data were abstracted by independent reviewers using a standardized abstraction form and the quality of methodology was scored. Distance technology applications were described in 6 categories: computerized communication, telephone follow-up and counseling, telephone reminders, interactive telephone systems, after-hours telephone access, and telephone screening. Data Synthesis.—Of 80 eligible clinical trials, 61 (76%) analyzed provider-initiated communication with patients and 50 (63%) reported positive outcome, improved performance, or significant benefits, including studies of computerized communication (7 of 7), telephone follow-up and counseling (20 of 37), telephone reminders (14 of 23), interactive telephone systems (5 of 6), telephone access (3 of 4), and telephone screening (1 of 3). Significantly improved outcomes were dem- onstrated in studies of preventive care, management of osteoarthritis, cardiac rehabilitation, and diabetes care. Conclusions.—Distance medicine technology enables greater continuity of care by improving access and supporting the coordination of activities by a clinician. The benefits of distance technologies in facilitating communication between clini- cians and patients indicate that application of telemedicine should not be limited to physician-to-physician communication. JAMA. 1997;278:152-159

Reprints: E. Andrew Balas, MD, PhD, School of Medicine, University of Missouri–Columbia, 324 Clark Hall, Columbia, MO 65211 (e-mail: [email protected]).

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