Preoperative risk assessment for bleeding and thromboembolism

doi:10.1136/bmj.b2299

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Donald M Arnold, assistant professor of medicine 13,
Julia Anderson, associate professor of medicine, consultant haematologist12,
Clive Kearon, professor of medicine1

¹Michael De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
²Department of Haematology, Royal Infirmary of Edinburgh, Edinburgh
³Canadian Blood Services, Hamilton, ON, Canada

Correspondence to: C Kearon, Hamilton Health Sciences, Henderson Division, 711 Concession Street, Hamilton, ON, Canada L8V 1C3 kearonc{at}mcmaster.ca

Personal and family histories are the most important assessments of a patient’s individual risk for bleeding and thrombosis with surgery, and will often rule out the need for routine coagulation testing

The patient

A 64 year old woman who is scheduled to have a total hip replacement is concerned that she may have a heightened risk of bleeding or thrombosis because she was told her father had died of a “clotting complication” after a car crash when he was 40 years old. It is not known if bleeding or pulmonary embolism was suspected of contributing to her father’s death. The patient would like to know if she should have testing before her surgery to find out if she is at risk for bleeding or venous thromboembolism.

What is the next investigation?

The next investigation depends on the patient’s personal and family history.

Personal medical history

The first and the most important step in the assessment of a patient’s personal risk of bleeding (figure)⇓ and thrombosis with surgery is to review the medical history and current drugs (use of anticoagulant or antiplatelet therapy, for example).

Assessing a patient’s risk of bleeding and thrombosis with surgery

Risk of bleeding

This patient has had three children, a tonsillectomy as a child, and a cholecystectomy, none of which was complicated by excessive bleeding. Based on clinical experience and a systematic review that evaluated the ability of a history of bleeding to predict postoperative bleeding,1 the lack of excessive bleeding after these major haemostatic challenges strongly suggests that she does not have a longstanding major bleeding disorder. She describes having heavy menstrual periods, but she …