術前 INR/aPTT 檢測與出血風險：最新系統性回顧分析

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這篇系統性回顧研究探討了手術前的凝血測試（INR和aPTT）與術後出血風險之間的關聯。研究發現，對於小型手術，凝血測試結果與出血事件之間幾乎沒有關聯。而對於大型手術，除了肝臟手術外，凝血測試的敏感性也很低，未能有效預測出血風險。該研究強調了儘管缺乏足夠證據支持，例行的術前凝血測試仍廣泛使用，並呼籲在此領域進行更多的研究。

Assessing Pre-Operative Bleeding Risk Using INR/aPTT: A Systematic Review

使用 INR/aPTT 評估術前出血風險：系統性回顧

Hassan Rahhal, Brandon Christopher Tse, Grace Tang, Michael Fralick, Lisa Hicks, Michelle Sholzberg Blood (2023) 142 (Supplement 1): 2318.

Abstract

The prothrombin time (PT) and activated partial thromboplastin time (aPTT) are often considered “routine” tests to assess perioperative bleeding risk. The PT and its mathematical derivative, the international normalized ratio (INR), allows for monitoring of vitamin K antagonist therapy. The aPTT was developed to screen for hemophilia A and B in family members of affected individuals. Both tests perform extremely poorly as screening tests for inherited bleeding disorders. Therefore, their utility in predicting peri-operative bleeding has been questioned.

The primary objective was to examine the relationship between pre-operative coagulation results and peri-operative bleeding in pediatric and adult patients undergoing elective surgery in the published literature.

A systematic review was conducted using a comprehensive search of MEDLINE, EMBASE, and grey literature between 1970 to July 2022. Randomized trials and observational studies that assessed the predictive accuracy of pre-procedural INR and aPTT test results for perioperative bleeding we deemed eligible for inclusion. Two reviewers independently screened and performed data extraction. A third reviewer adjudicated decisions when consensus could not be reached. Outcomes included any bleeding events in the postoperative period.
The study protocol was registered online on PROSPERO (CRD42023385588).

5700 articles were screened, and 79 studies were included in the systematic review. Major surgery (N=53) types included cardiac (n=14), neurosurgery (n=11), liver transplantation or resection (n=16) and general surgery (n=12). Minor surgeries included otolaryngology procedures (n=14) and other minor surgeries/procedures (e.g. pediatric spinal anesthesia, gastrointestinal endoscopy and related procedures, thoracocentesis, hernia repair, circumcision) (n=12). Bleeding complications were rare for minor surgeries and only one out of 26 studies found an association between coagulation test results and bleeding. Thirty-two out of 37 (86.5%) papers exploring other major surgeries found no association or reported a sensitivity under 50% between coagulation test results and bleeding (see Figure 1). Seven out of 16 studies (43.8%) on liver transplantation or resection found an association between the INR and bleeding (see Figure 2). None of the studies evaluated were randomized and none of the observational studies had outcomes adjudicated in blinded fashion.

Our findings confirm that bleeding events are rare in minor surgeries, and that coagulation testing is of limited utility in this setting. Similar conclusions can be drawn for patients undergoing major surgeries, with one exception – in patients with liver disease or liver cancer – as there may be an association between bleeding and the pre-operative INR with further studies required. Despite the absence of evidence supporting the practice, routine pre-operative coagulation testing remains prevalent, highlighting the need for targeted knowledge translation.

摘要

凝血酶原時間（PT）與活化部分凝血活酶時間（aPTT）通常被認為是評估圍手術期出血風險的「常規」檢測。PT 及其數學推導值國際標準化比值（INR）主要用於監測維生素 K 拮抗劑治療；aPTT 則最初用於篩檢家族性血友病 A 和 B。這兩項檢測作為篩查遺傳性出血性疾病的工具，表現極差。因此，其預測圍手術期出血的效用受到質疑。

主要目的是檢視術前凝血檢查結果與接受選擇性手術的兒科及成人患者圍手術期出血之間的關係，基於已發表文獻進行系統性回顧。

本研究進行了系統性回顧，全面檢索了 1970 年至 2022 年 7 月間的 MEDLINE、EMBASE 與灰色文獻。納入的研究包括隨機試驗及觀察性研究，評估術前 INR 與 aPTT 結果對圍手術期出血的預測準確性。由兩名審查者獨立篩選及提取數據，第三名審查者在意見不一致時進行裁定。研究結果包括術後期間的任何出血事件。研究計畫已於 PROSPERO 註冊（CRD42023385588）。

共篩選 5700 篇文章，最終納入 79 篇研究。主要手術類型（53 項研究）包括心臟手術（n=14）、神經外科手術（n=11）、肝臟移植或切除術（n=16），及一般外科手術（n=12）。次要手術類型包括耳鼻喉手術（n=14）及其他小型手術/程序（如小兒脊椎麻醉、胃腸道內視鏡及相關操作、胸腔穿刺、疝氣修補術、包皮環切術）（n=12）。

次要手術的出血併發症罕見，26 篇研究中僅 1 篇發現凝血檢測結果與出血有關。在研究主要手術的 37 篇論文中，32 篇（86.5%）未發現相關性或報告檢測的敏感性低於 50%（見圖 1）。在研究肝臟移植或切除術的 16 篇論文中，7 篇（43.8%）發現 INR 與出血相關（見圖 2）。納入的研究中無隨機試驗，且觀察性研究中結果均未以盲法裁定。

研究結果確認次要手術中出血事件罕見，凝血檢測在此情境中的實用性有限。對於主要手術患者，也得出了類似結論，但對於肝臟疾病或肝癌患者，術前 INR 與出血可能存在相關性，需進一步研究以確認。儘管缺乏證據支持，術前常規凝血檢測仍普遍進行，強調了需要針對性的知識傳遞以改進實踐。