Original Article

Role of bleeding time and clotting time in preoperative

hemostasis evaluation
Wg Cdr P Kinra *, Wg Cdr V Tewari +, AVM (Retd.)TS Raghu Raman#

ABSTRACT
A six months retrospective study was done to find out the utility of bleeding time (BT) and clotting time (CT)
in evaluation of preoperative hemostasis. All the BT and CT requested for preoperative evaluation were analysed
with other parameters determining the normal hemostasis. The sensitivity of bleeding time was only 20% and for
clotting time was 11.1%. This study highlights the drawbacks of this commonly misused hematology tests and
discusses the other more scientific alternatives during preanaesthetic workup of a patient.

IJASM 2009; 53(1): 56-61

Key Words: bleeding time, clotting time, preoperative evaluation

Introduction Material and Methods

Preoperative hemostasis evaluation has A six months retrospective study was carried
always been a significant factor in the minds of out at a large service hospital. All BT and CT
surgeons and anaesthetists before taking any case requested for preoperative hemostasis evaluation
for surgery. Since its initial invention by the French were analysed. The BT was carried out by the
worker Milian in 1901, the bleeding Duke’s method wherein a standard deep cut was
time has been put forward as a clinically useful made on the finger pulp with a lancet of 3mm depth,
test in three contexts: diagnosis (particularly the first drop of blood was wiped out subsequently
of platelet disorders), prediction of clinically the blood was blotted on a filter paper every 30 sec
important bleeding, and assessment of the adequacy until the blood stopped oozing. The normal BT by
of various forms of therapy. Whole blood this method is 1-5 minutes [1]. The whole blood
clotting time has been used in past to assess both clotting time was carried out by modified Dale’s
the intrinsic and extrinsic pathways of coagulation. method wherein the similar prick is made into the
finger pulp and blood is taken into a standard glass
Both these tests have gone to disrepute because of
capillary tube by the capillary action. Subsequent
inherent fallacies in the tests. The BT and CT are
to this the end of capillary tube is broken every 30
still being requisitioned as a routine preoperative
sec until the clot is formed and the end of capillary
test in many service hospitals. These two tests even
tube starts hanging. The normal clotting time by
if reported normal do not exclude bleeding diathesis
this method is 5-11 minutes [1]. The platelet count
as the results of both the tests are only altered after
was done by an automated hematology autoanalyser.
a significant fall of platelet or clotting factors as the
The PT and aPTT were performed as per standard
case may be. The preoperative workup of a patient
to rule out bleeding diathesis can be done by taking * Cl Spl (Path) 5 AFH C/o 99 APO
+
a careful history and a battery of more reliable Cl Spl (Path) Command Hospital, Bangalore-560007
#
tests. Former Commandant, Command Hospital, Bangalore-
560007

56 Ind J Aerospace Med 53(1), 2009

 Role of Bleeding and Clotting time: Kinra et al

protocols [2]. The platelet count, prothrombin time Table 3: Correlation of low platelet count with BT and
deranged PT/aPTT with CT
(PT) and activated partial thromboplastin time
(aPTT) if done in these patients were correlated Total No. Low Platelet Deranged Deranged
with the readings of BT and CT. A BT of >5min; (n= 912) Count PT aPTT

CT>11min; Platelet <1 lac/cmm and PT/ aPTT of No. Of Patients 10 36 20

>4 sec than control were considered abnormal. The Deranged BT 2 - -
Prolonged CT - 4 4
institutional control of PT was 14 sec and aPTT
False Negative 8 32 16
was 30 sec respectively.

Table 4: Statistical analysis (Plt Count Vs BT)

Results was done using chi square test.
A total of 912 BT & CT were carried out Platelet < Platelet > Total
during the study period for preoperative evaluation. 1 lac/cmm 1 lac/cmm
Out of these only three cases had high bleeding Deranged BT 2 1 3
time and five had prolonged clotting time. The total Normal BT 8 85 93
number of patients who underwent a simultaneous Total 10 86 96
platelet count, PT and aPTT is tabulated in
Table 5: Statistical analysis (PT Vs CT)
Table 1. was done using chi square test.

Deranged PT Normal PT Total

Table 1: Number of patients who underwent Platelet Deranged CT 4 1 5
count, PT & aPTT Normal CT 32 151 183
Total No. Platelet PT aPTT Total 36 152 188
(n= 912) Count
No. Of Patients 96 188 44 Table 6: Statistical analysis (aT Vs CT)
was done using chi square test.
The patients having low platelets, deranged Deranged Normal Total
PT & aPTT are tabulated in Table-2. aPTT aPTT
Deranged CT 3 1 4
Table 2: Number of patients having low platelet count,
deranged PT & aPTT Normal CT 16 23 39
Total 19 24 43
Total No. Low Platelet Deranged Deranged
(n= 912) Count PT aPTT
No. Of Patients 10 36 20 On applying chi square test for BT Vs platelet
Percentage(%) 10 19 40 count following values for BT have been derived.
False positive = 1, False negative = 8, Sensitivity =
The total of 366 patients out of the study group 0.2 (20%), Specificity = 0.988 (98.8%), Positive
(n= 912) required more than 2 points of whole blood predictive value = 0.667 (66.7%) Negative
transfusion/ fresh frozen plasma due to non surgical predictive value = 0.913 (91.3%), True positives =
bleeding. 2, True Negatives = 85.
The correlation of BT with platelet count and The correlation of CT with PT and aPTT
that of CT with PT and aPTT has been tabulated has been tabulated in Table 3,5&6. On applying
in Table 3,4,5&6. chi square test for CT Vs PT following values for

Ind J Aerospace Med 53(1), 2009 57

Role of Bleeding and Clotting time: Kinra et al

CT have been derived. False positive = 1, False out at 37°C (normal human temperature) and does
negative = 32, Sensitivity = 11.1%, Specificity = not have a clear cut end point. The test is commonly
99.3%, Positive predictive value = 80% Negative misinterpreted because only the initial traces of
predictive value 82.5%, True positives = 4, True thrombin formed is enough to cause the clotting in
Negatives = 151. On applying chi square test for the outermost part of column of blood within the
CT Vs aPTT following values were derived. False capillary tube [1]. The PT and aPTT comparatively
positive = 1, False negative = 16, Sensitivity = 20%, are more sensitive in the sense of being deranged
Specificity = 95.8%, Positive predictive value = 80% on dip of as less as 15% of concerned coagulation
Negative predictive value = 58.9%, True positives factors. It is carried out at 37°C and assesses the
= 4, True Negatives = 23. intrinsic and extrinsic pathway.

The bleeding time has been practiced for

Discussion
several decades in the way described in1910 by
The value of obtaining screening tests before Duke. Subsequent important modifications
surgery have been an issue of debate for years. attempted at standardizing the procedure were
The hemostasis in body is fulfilled by adequate introduced by Ivy et aI and Mielke et a1. Practically
functions of the vessel wall, adequate number/ unquestioned as to its clinical usefulness until the
function of platelets and an intact coagulation mid-l980s, despite the lack of appropriately
cascade. Vascular abnormalities like hemorrhagic controlled studies addressing the issue of its
telengectasia, hereditary connective tissue disorder, predictive ability with regard to the risk of actual
autoimmune, allergic and drug induced purpuras can bleeding, the validity of the bleeding time as a useful
be ruled out during a preanaesthetic check up by clinical test has been seriously questioned by a
careful examination. Bleeding diathesis in relation number of investigators [4]. Under discussion is
to platelets can be due to thrombocytopenia not so much the value of the test as an epidemiologic
(decreased production by marrow, increased or pharmacologic tool to explore primary
peripheral destruction) or due to platelet dysfunction. hemostasis, but rather its practical usefulness in
The coagulation factor deficiency of various grades predicting negative history of bleeding in situations
can lead to different types of bleeding disorders. in which the haemostatic system is seriously
challenged, such as during major surgery. De
The hemostasis has been divided into vascular/
Caterina performed linear regression analysis to
platelet phase and the coagulation phase. The tests
assess specificity, sensitivity, and positive and
available for the first phase are bleeding time, platelet
negative predictive values of BT. There was
count and platelet function assay [3]. The tests
relatively low correlation coefficients between the
available to test the coagulation phase of hemostasis
bleeding time and some of the alternative
are whole blood clotting time, plasma fibrinogen,
parameters and there was no significant relationship
prothrombin time, activated plasma thromboplastin
between any value derived from the bleeding time
time, thrombin time, d-dimers and inhibitors of
test and any index of actual bleeding [5].
coagulation. The conventional Dale’s method of
capillary tube clotting time has a significant The first drawback of this test is that it does
drawback of getting deranged only when there is a not discriminate between the platelet defect and
drop in coagulation factor of more than 40% of vascular defect. The old concept was that the
normal values. The test is not sensitive, is nor carried bleeding time is altered by platelets and vessel wall

58 Ind J Aerospace Med 53(1), 2009

 Role of Bleeding and Clotting time: Kinra et al

parameters. However of late there are various of bleeding diathesis but a sensitivity of BT as 20%
studies that have concluded that the BT is also vis-a-vis the platelet count clearly proves its
altered by hematocrit, skin quality and the technique inefficiency as a screening test for preoperative
[6,7,8]. The inter and intraobserver variation hemostasis. Platelet function is assayed better by
amongst the technicians is as high as 20% [4]. No aggregrometry when the index of suspicion is high.
two skin areas of the body are exactly the same Vascualr phase defects can be ruled out by a good
and do not give similar results [9]. There is no history and a careful examination. CT had a
absolute correlation of skin bleeding time and the sensitivity of only 11.1% vis-a vis PT, that clearly
extent of bleeding in the viscera during an operation signifies the fallacies of this test as a screening test.
[4]. It has been hypothesized that the main reason In the study population 36 patients required > 3 blood
for the lack of a relationship between the cutaneous bags/fresh frozen plasma. This set of patients
bleeding time and surgical bleeding lies in the multiple excludes the bleeding due to surgical causes of
determinants of surgical bleeding, which might bleeding. Only 4 out of these 36 patients had a
obscure, by their preponderant weight, the possible deranged CT and BT in preoperative evaluation.
predictive capacity of the bleeding time test. Linear At the same time 11 of these cases had undergone
regression analysis was applied to data from 23 platelet count, PT or aPTT. 10 of these 11 cases
studies relating platelet count to bleeding time, to had one of these values deranged again proving
assess published claims that the bleeding time and the superiority of these tests over BT and CT.
platelet count follow a predictively useful linear Further there was a loss of 3manhours per day
relationship. In 22 of 23 instances, the inverse to the hospital laboratory carrying out the BT &
relationship between bleeding time and platelet CT.
count was associated with broad statistical scatter,
making it impossible to predict precisely one variable General approach to preoperative hemostasis
given the other [5]. The pathophysiology of an evaluation includes careful history taking and first
abnormal bleeding time remains poorly understood. line screening tests. A history of a molar extraction
The bleeding time is affected by a large number of with brisk bleeding of less than 1 hour and oozing
diseases, drugs, physiologic factors, test conditions, less than 2 days signifies an intact haemostatic
and therapeutic actions, not all of them platelet- system [12]. A history of trauma with normal
related [5]. There have been studies showing no clotting, normal delivery and menstruation are also
statistical correlation between the preoperative BT important indirect markers of intact coagulation and
and the amount of surgical loss or the requirements vascular phase of hemostasis. The acquired
of the blood products [10,11]. bleeding disorders like disseminated intravascular
coagulation, leukaemia, drugs and purpuras (allergic,
In our study out of the entire study population drug induced) can easily be ruled out by proper
of 912 only 94 had undergone a platelet count. 10 examination and baseline investigations. The
of these patients had thrombocytopenia (<1 lac/ coagulation and platelet defects can be easily
cmm). Only 2 of these patients showing a deranged differentiated by simple history and examination as
BT. Out of the 36 patients who had a deranged shown in Table 7.
prothrombin time only 4 patients had a prolonged
clotting time. BT apart from platelet count is also a The laid down guidelines [13] for preoperative
marker for platelet function and the vascular reasons hemostasis is appended in Table 8.

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Role of Bleeding and Clotting time: Kinra et al

Table 7: Clinical distinction between Vascular/platelet disorder and coagulation disorder

Finding Coagulation Disorder Vascular/Platelet Disorder

Petechiae Rare Characteristic
Deep Dissecting Haematoma Characteristic Rare
Superficial ecchymosis Common Characteristic
Haemarthrosis Characteristic Rare
Delayed Bleeding Common Rare
Bleeding Superficial Cuts Minimal Persistent
Sex Male Female
Positive Family History Common Rare except vWD

Table 8 : Guidelines for preoperative hemostasis evaluation

Level Procedure Bleeding History Evaluation

I Minor Negative None
II Major Negative Platelet Count, aPTT
III Major involving hemostatic Equivocal Level II + PT, Factor XIII
impairement analysis, clot lysis time
IV Minor/Major Positive Level III +, Factor VIII, IX, XI, Platelet
aggregration test & Fibrinolytic tests

Certain disorders will even be missed by the platelet function, such as von Willebrand’s syndrome.
battery of first line screening tests (PT, aPTT, However, its application in preoperative analysis is
platelet count) which includes: von Willerbrand highly questionable due its low sensitivity. The whole
disease, mild inherited coagulation disorders, factor blood clotting time also has a very low sensitivity
XIII deficiency, dysfibrinogenemia, disorders of and negative predictive value. We recommend the
platelet function and allergic/vascular purpuras. A discontinuation of BT and CT as a routine
simple questionare can be developed by anaesthetist preanaesthetic checkup for hemostasis evaluation
during PA check up to exclude history of bleeding and should be replaced by the standard guidelines
diathesis in past [14,15]. mentioned above.

Conclusion References

The screening tests for hemostasis are not fully 1. Bharadwaj JR. Laboratory investigation of hemolytic
and purpuric disorders. In: Laboratory manual of
satisfactory to rule out mild forms of bleeding the armed forces 2001;1:41-54.
diathesis. Careful history taking and examination
2. Laffan MA, Bradshaw AE. Investigation of
can rule out these disorders especially when minor
hemostasis. In: Sir John Dacie, SM Lewis. Practical
th
surgery is planned. However screening tests are Haematology. 8 ed. Churchill Livingstone 2000: 297-
of value in high risk patients like patients of liver 316.
disease, biliary obstruction, renal disease, 3. Day HJ. Evaluation of platelet function. Semin
myelofibrosis and other myeloproliferative disorders. Haematol 1986; 23: 89-101.
The bleeding time test is likely to remain widely 4. Rodgers RPC. A critical reappraisal of bleeding time.
used for the diagnosis of inherited disorders of Semin Thromb Haemost 1990; 16:131-44.

60 Ind J Aerospace Med 53(1), 2009

 Role of Bleeding and Clotting time: Kinra et al

5. De Caterina R, Lanza M, Manca G, Strata GB, Maffei 11. Lehman CM. Discontinuation of BT without
S, Salvatore L. Bleeding Time and Bleeding: An detectable adverse clinical impact. Clin Chem 2001;
analysis of the relationship of the bleeding time test 47:1204-11.
with parameters of surgical bleeding. Blood 1994;
84: 3363-70 12. George M Rodgers. Diagnostic Approach to the
bleeding disorder. In: John P Greer, John Foerster.
th
6. Livio M. Uraemic bleeding: Role of anaemia and Wintrobes Clinical Haematology. 11 ed. Lippincott
beneficial effects of red cell transfusions. Lancet Williams & Wilkins 2003; 2: 1511-628.
1982; 2: 1013-5.
13. Rapaport SI. Preoperative hemostatic evaluation:
7. Weiss HJ. Fibrinogen and platelets in the primary Which tests, if any? Blood 1983; 61:229-31.
arrest of bleeding. N Engl J Med 1971; 285: 369-74.
14. Macpherson DS. Preoperative laboratory testing:
8. Evensen SA. Hemostatis study in osteogenesis
Should any test be routine before surgery? Med
imperfecta. Scan J Haematol 1984; 33:177-9.
Clin North Am 1993; 77: 289-90.
9. Lind SE. Prolonged Bleeding Time. Am J Med 1984;
77:305-12. 15. Marr BJ, Harsen TR, Warner MA. Preoperative
laboratory screening in healthy Mayo patients. Cost
10. Lind SE. The Bleeding time does not predict surgical effective elimination of tests and unchanged
bleeding. Blood 1991; 77: 2547-52. outcomes. Mayo Clinic Proc 1991; 66:155.

Ind J Aerospace Med 53(1), 2009 61