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 hemor- rhage 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 non- steroidal 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 his- tories. A history suggesting a possible bleeding disorder may require further evaluation; such an evalu- ation 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 rou- tine 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 hemor- rhagic 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 ARCH SURG/ VOL 133, FEB 1998 134 ©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 b-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 1003109/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 re- ceiver operating characteristic curves. The receiver op- Preoperative Evaluation of Risk of Bleeding erating characteristic curves from these studies indi- cated 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 ARCH SURG/ VOL 133, FEB 1998 135 ©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.