背景:术前确定止血异常导致出血风险增加的患者是基于常规止血试验:凝血酶原时间(PT),活化凝血酶原时间(aPTT),和血小板计数。由于其预测性能低,指南建议用结构化出血风险问卷代替,但在这个人群中没有一个是有效的。
目的:为了评估3种策略的诊断准确性,在预定的干预措施之前,在麻醉前访视时进行,确定止血异常导致出血风险增加的患者和方法:法国7家学术医院的多中心研究,涉及计划进行手术干预的患者,没有抗血小板/抗凝治疗。这3种策略包括1-a结构化筛查问卷;2-PT,aPTT,和部分患者的血小板计数;3-系统PT,aPTT,和血小板计数。参考标准包括血管性血友病因子活性/抗原,因素八,IX,XI,血小板功能分析仪,and,当需要时,FII,FV,FX,以及FVII和止血咨询。
结果:根据参考标准,1484例患者中有18例(1.2%)存在止血异常,导致出血风险增加。在整个队列中,基于问卷的策略的敏感性为50%(95CI,26-74;特异性为87%(95CI,85-88);男性的敏感性为0(95CI,0-41),女性的敏感性为82%(95CI,48-98).对于选择性常规测试,敏感性为33%(95CI,13-59),特异性为97%(95%CI,96-98).系统常规检查的相应值分别为44%(95CI,22-69)和93%(95CI,91-94)。
结论:所研究的所有3种策略的敏感性均较低。结构化筛查问卷仅在女性中具有临床上可接受的诊断准确性。
BACKGROUND: Preoperative identification of patients with haemostasis abnormalities leading to an increased bleeding risk was based on routine haemostasis tests: prothrombin time (PT), activated prothrombin time (aPTT), and platelet count. Because of their low predictive performance, guidelines recommend replacing them with structured bleeding risk questionnaires, but none is validated in this population.
OBJECTIVE: To assess the diagnostic accuracy of 3 strategies, performed at the pre-anaesthesia visit before scheduled interventions, to identify patients with haemostasis abnormalities leading to an increased bleeding risk PATIENTS AND METHODS: Multicenter study in 7 French academic hospitals, involving patients scheduled for surgical intervention, without antiplatelet/anticoagulant treatment. The 3 strategies consisted of 1-a structured screening questionnaire; 2-PT, aPTT, and platelet count ordered in selected patients; 3-systematic PT, aPTT, and platelet count. The reference standard comprised von Willebrand factor activity/antigen, factors VIII, IX, and XI, platelet-function analyser, and, when required, FII, FV, FX, and FVII and haemostasis consultation.
RESULTS: Eighteen (1.2%) of 1484 patients had a haemostasis abnormality leading to an increased bleeding risk according to reference standard. In the overall cohort, sensitivity of the questionnaire-based strategy was 50% (95%CI, 26-74; specificity 87% (95%CI, 85-88); sensitivity was 0 (95%CI, 0-41) in men vs 82% (95%CI, 48- 98) in women. For selective routine tests, sensitivity was 33% (95%CI, 13-59) and specificity 97% (95% CI, 96-98). Corresponding values for systematic routine tests were 44% (95%CI, 22-69) and 93% (95%CI, 91-94).
CONCLUSIONS: Sensitivity was low for all 3 strategies investigated. The structured screening questionnaire had clinically acceptable diagnostic accuracy only in women.