Should Factor VII levels be drawn before every surgical procedure?

From the Guidelines

Factor VII levels do not need to be drawn before every surgical procedure. This test is only necessary for patients with suspected or known Factor VII deficiency, a rare bleeding disorder, or for those on certain anticoagulants like warfarin 1. For most patients undergoing surgery, a standard preoperative coagulation panel (PT/INR, aPTT, platelet count) provides sufficient information about bleeding risk. Factor VII has a short half-life of 3-6 hours and is the first clotting factor to decrease in conditions like liver disease or vitamin K deficiency. Testing specifically for Factor VII is resource-intensive and unnecessary for routine surgical risk assessment.

Instead, surgeons should focus on obtaining a thorough bleeding history, reviewing medications that affect coagulation, and ordering appropriate standard coagulation tests based on the patient's clinical presentation and the planned procedure. The use of recombinant activated factor VII (rFVIIa) has been studied in the treatment of severe bleeding after surgery, but its efficacy remains unclear and it is not recommended for routine use in surgical procedures 1. The most recent and highest quality study on this topic is from 2018, which recommends the use of rFVIIa in specific situations, such as congenital FVII deficiency or Glanzmann’s thrombasthenia, but not as a routine measure for all surgical procedures 1.

Some key points to consider when evaluating the need for Factor VII levels include:

• The patient's medical history and risk factors for bleeding disorders
• The type of surgical procedure and its associated bleeding risk
• The use of anticoagulant medications and their potential impact on coagulation
• The results of standard coagulation tests, such as PT/INR and aPTT. In general, a thorough clinical evaluation and standard coagulation tests are sufficient for assessing bleeding risk in most patients undergoing surgery, and Factor VII levels do not need to be drawn routinely 1.

From the Research

Factor VII Levels and Surgical Procedures

• Factor VII deficiency is a rare inheritable bleeding disorder that can affect individuals to varying degrees, from asymptomatic to severe bleeding 2, 3.
• The decision to draw Factor VII levels before every surgical procedure depends on several factors, including the patient's bleeding history, the type of surgery, and the inherent bleeding risk of the procedure itself 4, 5.

Perioperative Management

• Studies suggest that a thorough bleeding history and Factor VII procoagulant activity levels (FVII:C) can help guide perioperative management of Factor VII-deficient patients 4, 5.
• A cut-off value of 7% FVII:C has been proposed, with a sensitivity of 87% and a negative predictive value of 94% for bleeding risk 4.
• However, due to potential variations in FVII:C measurements, a threshold of 10% has been suggested to enhance sensitivity 4.

Surgical Procedures and Bleeding Risk

• Minor procedures that risk only external or controlled hemorrhage can be performed in asymptomatic or mildly affected adults with FVII:C levels below 10% 4.
• Major surgical procedures may require replacement therapy with recombinant activated Factor VII (rFVIIa) to minimize bleeding risk 6.
• The use of rFVIIa has been shown to be effective in preventing excessive bleeding during surgical interventions in patients with Factor VII deficiency 6.

Laboratory Diagnosis and Patient Management

• Laboratory testing for FVII activity is the first-line method for diagnosing Factor VII deficiency and is helpful for managing patients in combination with clinical history 2.
• Additional testing, such as FVII immunoassay and genetic testing, can provide further information on the underlying defect and guide patient management 2.
• A personal and family history is essential to determine the bleeding risk and plan for surgical and obstetrical prophylaxis 3.