60-year-old lady for laparoscopic BSO – Preventative surgery

Background

• Family history of Ovarian Cancer
• Mild Asthma – No admissions or steroids. 
• Hypertension – single agent

Issues

• Bleeding Disorder – Patient unsure of name of condition, knows it is a platelet problem.
• Normal FBC and Coagulation Screen
• VWD most likely diagnosis
• First diagnosed 30 years ago – presented with epistaxis
• PPH after all births
• Life-threatening intraoperative haemorrhage requiring massive transfusion and ICU admission following elective D&C/Cone Biopsy
• Brother died following post-tonsillectomy bleed
• Telehealth Consult with haematologist recently – No letter available. Patient states they recommended Tranexamic acid and platelet cover preoperatively and oral tranexamic acid for 10 days postoperatively
• Concern about possible transfusion reaction – describes dyspnoea and lip swelling during massive transfusion episode
• Undergone 2 subsequent orthopaedic procedures with no bleeding – femoral nail in Japan and revision of femoral nail in Sydney. Both procedures performed under platelet cover.

Discussion

Coagulation Screening in Perioperative Clinic

• Few indications for routine perioperative testing
• https://perioperative.files.wordpress.com/2021/07/pre-operative-pathology-testing.pdf
• Discussion centred around taking an adequate bleeding history to determine requirements for further pathology testing/haematologist advice
• National Blood Authority Australia recommends standardised approach via a Bleeding Assessment Tool (BAT) as outlined in the following guideline:

• https://www.blood.gov.au/system/files/documents/preoperative-bleeding-risk-assessment-v5.pdf
• https://bleedingscore.certe.nl/ See case below for example of a BAT

Transfusion reaction

• Most likely scenario is symptoms were attributable to massive transfusion
• Early Group and screen for antibodies to identify any specific blood requirements preoperatively

Role for Thromboelastography?

• Evolving research in this area, especially in the acute and perioperative settings.
• TEG parameters of K-time and MRTG have been found to be effective in detecting patients with vWF:Rco < 30IU/dL (Diagnostic value <60)
• See attached article on bleeding disorders and anaesthesia

Plan

• Chase Haematologist letter and inform local team preoperatively to ensure we have all possible products required
• Postpone surgery for shortest possible time until haematology review occurs.