It is essential that clinicians are able to identify and assess which patients are in the high risk category for bleeding during ENT surgery. A full history, including medications, herbal remedies taken, any other medical co-morbidities and family history of bleeding tendencies is the best screening method to determine the requirement for any further haematological work-up. Common medications affecting haemostasis are: vitamin K antagonists (warfarin), unfractionated heparin, low-molecular weight heparin, direct factor Xa inhibitors (rivaroxiban), direct thrombin inhibitors (dabigatran), antiplatelets (clopidogrel, aspirin) and non-steroidal anti-inflammatory.

Herbal supplementation is on the increase so it is important to understand that they can have a significant impact on perioperative haemostasis. Common herbal remedies affecting haemostasis are: garlic, ginkgo biloba, ginseng and ginger.

On examination it is imperative to look for petechiae, ecchymosis, telangiectasia, stigmata of prior haemarthroses, haematomas, stigmata of Ehler-Danlos; hyperelastic skin, hyperflexible joints and stigmata of vitamin C deficiency; bleeding gums and poor wound healing. Laboratory testing is advisable for high risk surgery even in patients without a prior history of bleeding tendencies, as patients may have an acquired deficiency or factor XI deficiency that may lead to significant bleeding only after major surgery or trauma. These would include prothrombin time, international normalised ratio, partial thromboplastin time, thrombin time and platelet count. Thorough preoperative assessment is necessary for patient safety and optimal surgical outcome. Finally, it is vital to understand that each anticoagulant has a specific discontinuation period, a specific bridging technique and a different antidote.

Preoperative assessment of risk factors.
Tassler A, Kaye R.
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Sheneen Meghji

MBChB, BSc(Hons), MRCS(ENT), Cambridge University Hospital, East of England, UK.

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