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A Practical Guide to Haemostasis


Assessing the Risk of Bleeding

Introduction

The assessment of the severity of bleeding symptoms in any patient under investigation for a possible bleeding disorder is fundamental and in an attempt to improve the collection and reproducibility of the bleeding history, several Bleeding Assessment Tools (BAT) have been developed.

There are limitations to a number of these algorithms in particular in relation to paediatric patients due to a lack of expose to bleeding risk events.  Similarly individuals with an acquired bleeding disorder may have a misleadingly low score.

These bleeding scores are not designed to assess the bleeding risk of an individual about to commence anticoagulation for example in someone with Atrial Fibrillation [AF] or a venous thrombosis, these are covered in a separate section of Practical-Haemostasis.com.


The ISTH Bleeding Assessment Template [BAT]


The ISTH BAT comprises 14 categories for assessing bleeding symptoms retrospectively and it has been shown that a high bleeding score is associated with the presence of an inherited bleeding disorder. 

The ISTH-BAT is relatively insensitive to children with a possible inherited bleeding disorder and this may lead to an underestimation of bleeding symptoms.   In addition the ISTH-BAT is inflexible with respect to changes in the bleeding phenotype of the developing child.

Click HERE to access the ISTH-BAT.

The IMPROVE Bleeding Risk Score


The IMPROVE bleeding risk score estimates the risk of bleeding among acutely ill hospitalised patients.

Click HERE to access the IMPROVE Bleeding Risk Score.


The Pediatric Bleeding Questionnaire [PBQ]


The PBQ was developed screen children for von Willebrands Disease. The PBQ and the ISTH-BAT are relatively insensitive to children with a possible inherited bleeding disorder and this may lead to underestimation of bleeding symptoms.   In addition the ISTH-BAT is inflexible with respect to changes in the bleeding phenotype of the developing child.

The accurate assessment of haemorrhagic symptoms, which is a critical component in the diagnosis of mild bleeding disorders such as von Willebrand disease (VWD), can be particularly difficult in children.

Click HERE to access the PBQ.

Identifying Children with HEreditary Coagulation Disorders: The iCHEC Bleeding Assessment Template


The iCHEC is a development of the ISTH-BAT and PBQ recognising that both of these lack sensitivity in children and may underestimate bleeding symptoms. 

For additional information on the iCHEC assessment template see References Casey et al 2017 and Stokhuijzen et al 2018.

 

Bleeding Score System for Rare Inherited Bleeding Disorders


A Bleeding Score System [BSS] has been developed for the investigation of a suspected rare bleeding disorder and has proved effective in separating individuals with a bleeding disorder from those without. 

For further information see Palla et al 2016 - Reference 9.

The authors have also generated an Excel spreadsheet that allows the user to input data and to calculate the probability that an individual will have a rare bleeding disorder.  The spreadsheet is available as part of the supplementary information provided with the paper.