Should blood coagulation tests be performed before locoregional anesthesia in class 1 ASA patients?

Coagulation testing is warranted before regional anaesthesia to avoid bleeding complications. The most feared is spinal epidural hematoma causing neurologic deficits if epidural or spinal anaesthesia is performed in patients with hemostatic defects. These concepts are submitted to critical appraisal in the special setting of ASA class 1 patients. If patients are correctly assessed by questionnaire and physical examination as having negative history, asymptomatic coagulopathies are very scarce, mainly represented by hemophilia in men and von Willebrand's disease in women. Activated partial thromboplastin time (APTT) is the main test to assess coagulation defects. APTT is not sufficiently sensitive to identify all patients with coagulopathies, especially mild ones and von Willebrand's disease. Medium specificity combined with low prevalence of the disease to be screened incur false positive results and poor predictive value of positive tests as well for diagnostic purpose as for prognostic evaluation of haemorrhagic risk. Neurologic deficits secondary to compression by haematoma are rare and their frequency presently unknown. Epidural or spinal anaesthesia has been shown to be quite safe when performed in patients with various hemostatic abnormalities. Consequently, routine coagulation testing in ASA class 1 patients seems to provide more drawback than benefit. Lack of coagulation testing prior to regional anaesthesia is probably not a factor of increased risk if patients are correctly assessed.