PATIENT SAFETY Outcomes Article Evidence-Based Patient Safety Advisory: Blood Dyscrasias Phillip C. Haeck, M.D. Summary: Rarely, patients with blood disorders may seek to undergo plastic Jennifer A. Swanson, B.S., surgery. Although plastic surgeons are not expected to diagnose or manage M.Ed. blood disorders, they should be able to recognize which patients are suitable for Loren S. Schechter, M.D. surgery and which should be referred to a hematologist before a procedure. This Elizabeth J. Hall-Findlay, practice advisory provides an overview of the perioperative steps that should be M.D. completed to ensure appropriate care for patients with blood disorders. (Plast. Noel B. McDevitt, M.D. Reconstr. Surg. 124 (Suppl.): 82S, 2009.) Gary A. Smotrich, M.D. Neal R. Reisman, M.D., J.D. Scot Bradley Glasberg, M.D. and the ASPS Patient Safety Committee Arlington Heights, Ill. he term “blood dyscrasia” refers to any several steps by means of anticoagulant mech- pathologic condition of the blood involving anisms to ensure that the clotting process re- Tdisorders of the blood’s cellular components mains localized to the area of damage. (platelets, white blood cells, or red blood cells) or Hypocoagulable patients typically have diffi- soluble plasma components required for proper culty controlling bleeding as a result of decreased coagulation (coagulation factors). In general, platelet numbers or loss-of-function mutations af- most of these blood disorders can be broken down fecting specific clotting factors. By contrast, hy- into two basic categories based on the patient’s percoagulable patients typically exhibit excessive coagulation phenotype: hypocoagulable (hemor- thrombus formation resulting from hyperactive rhagic) states and hypercoagulable (thrombotic) platelet aggregation, increased platelet numbers, states. Each category includes heritable and ac- or mutations affecting the function of specific clot- quired causes. ting factors (Fig. 1). Whatever the source of the During normal hemostasis, various factors defect in the coagulation cascade, these patients’ operate in combination to arrest bleeding after risks of bleeding or thrombosis during surgery is vascular injury. Early in the coagulation re- increased significantly over the normal patient, sponse, platelets aggregate to form a plug at the and complications may result if they are not di- site of the ruptured vessel. After initial bleeding agnosed or treated appropriately. control has been achieved, the platelet plug is There is a paucity of published clinical re- stabilized by means of fibrin deposition, effec- search pertaining to the perioperative care of sur- tively sealing the break in the vessel and pre- gical patients with blood dyscrasias. In an effort to venting further bleeding. Fibrin deposition is ensure patient safety, the American Society of Plas- initiated by a cascading series of proteolytic tic Surgeons (ASPS) Patient Safety Committee events involving coagulation factors (Fig. 1). sought to develop a practice advisory to assist de- This efficient coagulation system is controlled at cision-making for patients with blood disorders who seek to undergo elective surgical procedures. From the American Society of Plastic Surgeons’ Patient Safety The current practice advisory thus provides an Committee. overview of the perioperative steps that should be Received for publication March 3, 2009; accepted May 27, completed to ensure appropriate care for these 2009. patients. These guidelines are designed for use by Approved by the ASPS Executive Committee, January 10, 2009. The members of the ASPS Patient Safety Committee are listed at the end of this article. Disclosure: The authors have no financial con- Copyright ©2009 by the American Society of Plastic Surgeons flicts related to this article. DOI: 10.1097/PRS.0b013e3181b54640 82S www.PRSJournal.com Volume 124, Number 4S • Blood Dyscrasias Fig. 1. The coagulation cascade and associated defects. any health care practitioner managing the peri- the levels of evidence provided by the supporting operative care of patients with bleeding disorders. literature for that recommendation. Practice rec- Although plastic surgeons are not expected to ommendations are discussed throughout this doc- manage hypocoagulable and hypercoagulable dis- ument, and graded recommendations are sum- orders, they should be able to recognize which marized in Appendix A. patients are suitable for surgery and which should be referred to a hematologist before a procedure. DISCLAIMER This patient safety advisory was developed through a comprehensive review of the scientific Practice advisories are strategies for patient literature and a consensus of the Patient Safety management, developed to assist physicians in Committee. The supporting literature was criti- clinical decision-making. This practice advisory, cally appraised for study quality according to cri- based on a thorough evaluation of the present teria referenced in key publications on evidence- scientific literature and relevant clinical experi- based medicine.1–5 Depending on study design ence, describes a range of generally acceptable and quality, each reference was assigned a corre- approaches to diagnosis, management, or preven- sponding level of evidence (I through V) with the tion of specific diseases or conditions. This prac- ASPS Evidence Rating Scale (Table 1),6 and the tice advisory attempts to define principles of prac- evidence was synthesized into practice recommen- tice that should generally meet the needs of most dations. The recommendations were then graded patients in most circumstances. However, this (A through D) with the ASPS Grades of Recom- practice advisory should not be construed as a mendation Scale (Table 2)7; grades correspond to rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining Table 1. Evidence Rating Scale for Studies Reviewed the appropriate results. It is anticipated that it will be necessary to approach some patients’ needs Level of Evidence Qualifying Studies in different ways. The ultimate judgment re- I High-quality, multicentered or single-centered, garding the care of a particular patient must be randomized controlled trial with adequate made by the physician in light of all the circum- power; or systematic review of these studies stances presented by the patient, the diagnostic II Lesser quality, randomized controlled trial; prospective cohort study; or systematic review and treatment options available, and available of these studies resources. III Retrospective comparative study; case-control This practice advisory is not intended to define study; or systematic review of these studies IV Case series or serve as the standard of medical care. Standards V Expert opinion; case report or clinical of medical care are determined on the basis of all example; or evidence based on physiology, the facts or circumstances involved in an indi- bench research, or “first principles” vidual case and are subject to change as scien- 83S Plastic and Reconstructive Surgery • October Supplement 2009 Table 2. Scale for Grading Recommendations Grade Descriptor Qualifying Evidence Implications for Practice A Strong Level I evidence or consistent findings Clinicians should follow a strong recommendation recommendation from multiple studies of levels II, III, unless a clear and compelling rationale for an or IV alternative approach is present. B Recommendation Levels II, III, or IV evidence and Generally, clinicians should follow a recommendation findings are generally consistent but should remain alert to new information and sensitive to patient preferences. C Option Levels II, III, or IV evidence, but Clinicians should be flexible in their decision-making findings are inconsistent regarding appropriate practice, although they may set bounds on alternatives; patient preference should have a substantial influencing role. D Option Level V: Little or no systematic Clinicians should consider all options in their empirical evidence decision-making and be alert to new published evidence that clarifies the balance of benefit versus harm; patient preference should have a substantial influencing role. tific knowledge and technology advance, and as tions to ask patients during the preoperative assess- practice patterns evolve. This practice advisory ment (Appendix B). reflects the state of knowledge current at the Although routine screening of all patients is not time of publication. Given the inevitable recommended, patients who have a positive history changes in the state of scientific information for bleeding, bruising, or thrombosis should un- and technology, periodic review and revision dergo preoperative coagulation and/or thrombo- will be necessary. philia screening.8,16,17 Initial hemostasis laboratory tests may include platelet count and complete blood count, activated partial thromboplastin time, pro- PATIENT SELECTION thrombin time, and optionally either a fibrinogen Medical care has become sufficiently ad- level or a thrombin time.8,16 Bleeding time may be vanced that patients with complex blood disorders useful to detect severe blood disorders, but is often can safely undergo a variety of surgical proce- unreliable for detecting mild or moderate cases.8,16 dures. However, there remain inherent risks asso- If initial tests are positive or inconclusive, referral ciated with any surgical procedure, and these can be may be necessary for further evaluation. exacerbated in patients with