Preoperative Assessment of Hemostasis
Stop Doing Bleeding Times!
Lt Col Lucia E. More
United States Air Force
Why Not Bleeding Time?
Not reliable as a screening test
Affected by location of the incision,
pressure applied, operator experience, and
patient factors such as age, gender, diet,
hematocrit, skin laxity, medications, etc.
Why Not Bleeding Time?
In the absence of a clinical history of a bleeding
disorder, the bleeding time is not a useful
predictor of the risk of hemorrhage associated
with surgical procedures;
A normal bleeding time does not exclude the
possibility of excessive hemorrhage associated
with invasive procedures.
Recommendations for preoperative
assessment of hemostasis
Careful clinical history including family, dental, obstetric,
surgical, traumatic injury, transfusion, and drug history.
Physical examination; findings suggestive of a potential
bleeding disorder; the presence of petechiae or
ecchymoses, telangiectasias, evidence of past hemarthroses
(joint deformities in a patient with a positive bleeding
history), hematomas etc.
Evaluate specific surgical procedures and their bleeding
Low Risk Surgery
Nonvital organs are involved
The surgical site is exposed
There is a limited degree of surgical dissection
Local hemostatic measures are likely to be
The site does not have local fibrinolysis
i.e. lymph node biopsy, herniorrhaphy, dental
Moderate/high risk surgical procedures
Prostatic surgery, tonsillectomy, oral or nasal surgery,
closed liver or kidney biopsy, cardiopulmonary bypass,
brain injury, extensive malignancy, laparotomy,
thoracotomy, mastectomy, neurosurgical and ophthalmic
procedures, as well as surgical procedures employed to
stop bleeding. Most laparascopic procedures would fall
into this category as well (e.g., arthroscopic orthopedic
procedures, gynecologic laparoscopy, and laparascopic
cholecystectomy or splenectomy).
So, what should we do instead?
– Use flowchart to identify potential
– Refer patient to larger facility/network
provider who can evaluate the patient
Larger labs: PFA 100
Combined measure of platelet adhesion and
Detection of congenital inherited and acquired platelet
Screens for von Willebrand disease
Assesses the anti-platelet effect of Aspirin
Evaluates platelet dysfunction in children
Evaluates platelet dysfunction in multiple clinical settings
such as high bleeding risk surgery, high-risk pregnancy
Most common hemostatic disorders can be ruled
out w/ PT/APTT, platelet count, platelet function
If PFA-100™ abnormal, further platelet function
tests, including aggregometry and vWF testing,
will be required for diagnosis.
Results < 5 minutes; $ 10 - $20 depending on
Abundant evidence has been accumulated
that the bleeding time is not reliable as a
screening test for perioperative bleeding.
Most non-military hospitals stopped doing
the test 10 years ago!
Burns ER, Lawrence C. Bleeding Time: A Guide to its
Diagnostic and Clinical Utility. Arch Pathol Lab Med,
Gewirtz AS, Miller ML, Keys TF. The Clinical
Usefulness of the Preoperative Bleeding Time. Arch
Pathol lab Med, 1996;120:353-356.
Peterson P et al: The Preoperative Bleeding Time Test
Lacks Clinical Benefit. Arch Surg, 1998;133:134-139.