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H. CALHOUNKARENMDB. KUPPERSMITHRONALDMD
Hartnick and Ruben have done an excellent job reviewing the controversial topic of coagulation studies prior to tonsillectomy. In my community, the surgeons seem to be about equally divided between those who always obtain preoperative PTs and PTTs and those who obtain preoperative studies in only selected patients as indicated by history. I personally order no laboratory studies on a routine basis for these patients, but I completely understand why my partners and colleagues do. I think all of us would like to think we are doing everything possible to prevent the life-threatening complication of postoperative hemorrhage. If I thought that a PT, PTT, and/or BT would help predict and ultimately avoid this complication, I would happily accept the additional discomfort and cost (I say "I" would; the insurance carrier might not).
John H. Nowlin, MD
My problem is that after reviewing this topic in the literature and with my hematologic and surgical colleagues for many years, I am not sure that there is a better predictor of hemostatic competency than a careful preoperative history. I have a standard set of questions that I ask the parents of my patients concerning abnormal bleeding after any previous surgery, dental extractions, or loss of primary teeth. I ask about problems with easy bruising, frequent nosebleeds, or abnormal bleeding after cuts or abrasions. I also inquire as to any family history of any of the above problems or of coagulation disorders. Any positive responses lead me to obtain selected laboratory studies or consultation with my hematology colleagues. The number of children who undergo preoperative studies is very small (much less than 1%).
In the past I routinely obtained a PT and PTT on all prospective tonsillectomy patients and commonly found abnormal values that required repeated studies, the results of which were usually normal. This finding and consultation with the literature led me to gradually adopt my current policy. My habits were reinforced by a prospective study in which I participated reviewing hemostatic assessment prior to tonsillectomy. Ninety-six patients underwent tonsillectomy after completing a preoperative questionnaire and PT and PTT. Six patients had positive responses on the questionnaire. One of the 6 had abnormal laboratory results suggestive of VWD. All 6 underwent uneventful surgery with no postoperative bleeding. Of the 90 patients with negative questionnaires, 16 had abnormal laboratory results: 14 had prolonged PTTs; 1, a prolonged PT; and 1, a mildly decreased PLT. None of these patients had postoperative bleeding or excessive operative blood loss. All of the patients who had postoperative bleeding had normal laboratory results.1
In summary, I agree with Hartnick and Ruben that the issue is unsettled and unsettling. I do not order routine studies, but I do see my share of postoperative bleeding in my patients. I understand why some of my colleagues order preoperative laboratory studies, but I am not convinced that they do not see their share of postoperative bleeding despite this testing.
Nowlin JH. Coagulation Studies Prior to Tonsillectomy: An Unsettled and Unsettling Issue. Arch Otolaryngol Head Neck Surg. 2000;126(5):687. doi:10.1001/archotol.126.5.687
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