title: Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence?
abstract: Standard laboratory coagulation tests (SLTs) such as prothrombin time/international normalized ratio or partial thromboplastin time are frequently used to assess coagulopathy and to guide haemostatic interventions. However, this has been challenged by numerous reports, including the current European guidelines for perioperative bleeding management, which question the utility and reliability of SLTs in this setting. Furthermore, the arbitrary definition of coagulopathy (i.e. SLTs are prolonged by more than 1.5-fold) has been questioned. The present study aims to review the evidence for the usefulness of SLTs to assess coagulopathy and to guide bleeding management in the perioperative and massive bleeding setting. Medline was searched for investigations using results of SLTs as a means to determine coagulopathy or to guide bleeding management, and the outcomes (i.e. blood loss, transfusion requirements, mortality) were reported. A total of 11 guidelines for management of massive bleeding or perioperative bleeding and 64 studies investigating the usefulness of SLTs in this setting were identified and were included for final data synthesis. Referenced evidence for the usefulness of SLTs was found in only three prospective trials, investigating a total of 108 patients (whereby microvascular bleeding was a rare finding). Furthermore, no data from randomized controlled trials support the use of SLTs. In contrast, numerous investigations have challenged the reliability of SLTs to assess coagulopathy or guide bleeding management. There is actually no sound evidence from well-designed studies that confirm the usefulness of SLTs for diagnosis of coagulopathy or to guide haemostatic therapy.
authors.affiliation: Department of Anaesthesia, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland thorsten.haas@kispi.uzh.ch.
authors.forename: T
authors.initials: T
authors.lastname: Haas
authors.affiliation: Department of General and Surgical Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
authors.forename: D
authors.initials: D
authors.lastname: Fries
authors.affiliation: Department of Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH C-215, Pittsburgh, PA, USA.
authors.forename: K A
authors.initials: KA
authors.lastname: Tanaka
authors.affiliation: Unilabs, Coagulation Lab and Centre for Perioperative Thrombosis and Hemostasis, Hufgasse 17, 8008 Zurich, Switzerland.
authors.forename: L
authors.initials: L
authors.lastname: Asmis
authors.affiliation: Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK.
authors.forename: N S
authors.initials: NS
authors.lastname: Curry
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre, Salzburg Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Schöchl
mesh_terms: D001778:Blood Coagulation Disorders / Q000175:diagnosis* / Q000628:therapy*; D001780:Blood Coagulation Tests; D019317:Evidence-Based Medicine; D006470:Hemorrhage / Q000175:diagnosis* / Q000628:therapy*; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis / Q000628:therapy; D019990:Perioperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000628:therapy
keywords: bleeding; blood; coagulation; coagulopathy; transfusion