60-year-old lady for laparoscopic BSO – Preventative surgery
- Family history of Ovarian Cancer
- Mild Asthma – No admissions or steroids.
- Hypertension – single agent
- 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.
Coagulation Screening in Perioperative Clinic
- Few indications for routine perioperative testing
- 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://bleedingscore.certe.nl/ See case below for example of a BAT
- 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
- 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.