The preoperative evaluation before T/AD surgeries is important and should emphasis bleeding risks.
When we compared, qualitatively and quantitatively, the coagulation tests' results between the group of bleeders and non-bleeders, neither abnormal results nor the value of the results showed a significant difference between the groups (Tables 1 & 2). The rate of bleeders in patients with normal coagulation tests was 11.6%, while in the group with abnormal blood tests was 19.2%, these higher rates in the bleeding group were not statistically significant, but can still give a feeling that coagulation tests though not sensitive in predicting bleeding, may have additional value and should not be initially invalidated. We agree with the opinion of many researchers that it may not be necessary to perform these tests in every child prior to T/AD [4–6,9,10], however, we recommend these tests in any child with a positive medical history or questionnaire. When both the questionnaire and the coagulation tests are positive, pediatric hematologist consultation should be considered. Coagulation tests may further ascertain the normal risk for bleeding in some cases and may unveil some hidden conditions that are worth managing before surgery. Children with complex medical conditions such as obesity, and craniofacial abnormalities or syndromes, are to be considered for performing coagulation tests before surgery. These children are at increased risk for surgical or anesthetic complications , and any further post-operative re-intervention may carry a higher general risk.
Seeking relevant personal and family history prior to T/AD surgery is widely accepted. In our study, obtaining medical history before surgery, using standardized questionnaire, could predict higher risk for bleeding after T/AD surgeries in children, therefore, further evaluation of these children should be considered. Standardization of medical history using a dedicated questionnaire has the advantage of standardizing the assessment process among various medical personnel and avoids omitting portions of the relevant history. Our impression is that both the caregivers and the patients’ family are comfortable using this questionnaire, in a relatively short time and with ease. This tool is concise, cheap, noninvasive, and facilitates acquiring a complete history and physical examination.
Four children had both abnormal coagulation test and abnormal questionnaire, two of them (50%) bled (p = 0.08, Table 3) and one required treatment in the operating room. Although not statistically significant, this could be due to a small sample size. Probably, a combined abnormal questionnaire along with abnormal coagulation tests improves the ability to predict the risk to bleed better than each alone, we recommend hematological consultation for these patients before surgery.
The overall bleeding rate in this study was 12.5%. The reported rate in the literature is usually between 2–7% [5,6], other reports suggest a wider range of up to 20% [7,8]. At a glance, it seems that the bleeding rate in our study is higher than that reported, but other factors should be taken into consideration in this analysis. Firstly, it is a prospective study with a fixed post-operative follow-up; every bleeding event, even though very minor is reported and documented. In our study, in most children who were reported as bleeders (10 out of 18), the bleeding had stopped spontaneously and they were followed at home. Five children presented to the emergency room and were admitted to hospital for observation with no intervention. Only 3 patients (2.1%) returned to the operating room for control hemorrhage. This rate is consistent with the literature. Secondly, there is a wide variation in the reported rate of bleeding in literature (2 to 20%), which arises mainly from different size and age structures of patient's population, various indications for surgery, studies type, and different duration of post-operative follow up . Therefore, the bleeding rate in our study is acceptable.
In conclusion, in this study we show that routine pre-operative coagulation tests before T/AD surgeries in children is not necessary and should be reserved for special risk population. Pre-operative abnormal standardized medical questionnaire was found to accurately predict children with higher risk to bleed after T/AD surgeries and should routinely be used in the evaluation process before surgery. When the questionnaire reveals a risk, further workup including coagulation tests and / or pediatric hematology consultation should be considered.