R. G. Craig, Alder Hey Children's NHS Foundation Trust, UK

Background and context

A review of 19 patients who underwent major spinal surgery after haematology referral between October 2020 and August 2023 was performed to develop a standard operating procedure (SOP) for the investigation and referral process. Patients having major spinal surgery, such as posterior instrumented fusion for correction of scoliosis, at Alder Hey Children’s Hospital routinely have a clotting screen including prothrombin time (PT) and activated partial thromboplastin time (APTT) as part of their pre-op work-up. An abnormal result requires investigation and may require referral to a haematologist. Failure to adequately investigate was associated with major haemorrhage in two cases and short notice cancellation in three cases.1


19 patients referred to haematology went on to have planned spinal surgery between October 2020 to August 2023. There was no mortality due to bleeding. Two patients had major haemorrhage that was well managed and did not result in harm.

3 patients were cancelled on the day of surgery for the initial referral to haematology.

2 patients had neuromonitoring issues although a causal link to bleeding is not evident.

8 patients had adolescent idiopathic scoliosis (42%).

12 patients were referred for prolonged PT alone (63%).

10 patients were seen in haematology clinic.

9 patients had a specific haematology plan.

12 patients received Vitamin K therapy pre-op.

8 patients received enteral tranexamic acid 24 hours pre-op and for 3 – 7 days post-op.

2 patients received FIBRYGA on induction.

2 patients received FFP on induction.

2 patients received VONCENTO.

2 patients received platelet transfusion on induction.

10 patients required transfusion of allogeneic blood/ blood components intra-op and/or post-op (53%).

Investigation revealed the following diagnoses:

  • Acquired clotting abnormalities due to dietary deficiency.
  • Vitamin K deficiency.
  • Low factor VII – 4 patients; 53%, 43%, 50%, 20%
  • Von Willebrand disease – 1 new diagnosis; 1 known to have the condition.
  • Drug induced thrombocytopaenia – 2 patients.
  • Probable immune thrombocytopaenia
  • Low factor XII – 41%
  • Borderline factor V – 45%

Strategy for change

In collaboration with the haematology department and the spinal specialist nurses, a structured SOP has been developed for investigation and referral of abnormal coagulation test results as part of the pre-op work-up.

Measures of improvement

Implementation of the SOP will be audited.

Lessons learnt

A pre-op clotting screen is of great value and a failure to investigate even minor abnormalities is associated with a risk of major haemorrhage in the context of spinal surgery.

Message for others

Coagulation tests remain an important part of the pre-op work-up for major spinal surgery. Vitamin K deficiency is relatively common. Failure to investigate even minor abnormalities carries risk.

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