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![BRIDGING ANTICOAGULATION
Involves the administration of a short-acting anticoagulant
LMW heparin or
Unfractionated heparin
Aim - to minimize the time the patient is not
anticoagulated, thereby minimizing the risk for
perioperative thromboembolism
High thromboembolic risk with prolonged interruption of
their anticoagulant [VKA])](https://image.slidesharecdn.com/anticoagulantinsurgery-220311153404-241004223617-e70ccef3/75/anticoagulantinsurgery404-pd-use-and-analysis-39-2048.jpg)
![URGENT/EMERGENT INVASIVE PROCEDURE
Warfarin
If semi-urgent (eg, within one to two days),- warfarin should
be withheld and vitamin K administered (eg, 2.5 to 5.0 mg of
oral or intravenous).
If immediate reversal - prothrombin complex concentrates
(PCCs) or plasma products (eg, Fresh Frozen Plasma [FFP],
thrombotic risk associated with these products
used only if there is life-threatening bleeding and
prolongation of the INR by a vitamin K antagonist](https://image.slidesharecdn.com/anticoagulantinsurgery-220311153404-241004223617-e70ccef3/75/anticoagulantinsurgery404-pd-use-and-analysis-42-2048.jpg)
anticoagulantinsurgery404.pd use and analysis
- 1. Anticoagulant in surgery DrTenzin Yoezer
- 2. History 47 yearold G5P3A1L3 (Abortion at 2 months) Admitted at 41 weeks for IOL At the booking Wt = 95 kg BMI = 45.24 Kg/m2 Not known case of HTN/ DM Screening for HTN and DM at booking – Negative No fetal anaomalies at regular USG scan
- 3. At T3 Mildpedal swelling constipation No SOB No calf pain No frontal head ache
- 4. All previousdeliveries were SVD No complications PSHx – LEEP in 2003 Social hx- business first child from second marriage age of last child – 21years
- 5. After admission CTG– reactive Sweeping Ordered CBC, Blood grouping and cross-matching, FBS and PPBS Synto 2.5 U started Inj LMWH 80 mg SC OD (Mane)-as for prophylaxis DVT
- 6. During grand ward-round Clinically SFH > POG Urgent USG EFW – 4.173 kg +/- 690 g AFI – 9.4 cm Emergency LSCS but she was on LMWH Planned for Elective LSCS + TL Discontinue LMWH morning dose on the day of surgery
- 7. Examination Ht- 145cm Wt – 105 kg (IBW = 40 kg) BMI – 50 kg/m2 Comfortable Afebrile Not pale Mild pedal oedema
- 8. PR –80bpm BP – 130/80 mmHg NO murmur RR – 20 bpm, VB, Grade 2 Mallampati SFH – 47 cm Cephalic presentation
- 9. Investigation WBC –6.43 Hb – 15.7 g/dL Hct – 42.5% PLT – 257 FBS – 110 mg/dL 2 hr PP – 109 mg/dL PT – 14 sec ( 13.6 – 17.5) INR – 0.85
- 10. Problem list 1. Morbidobesity 2. Elderly mother 3. On LMWH 4. Large baby 5. Grand Multi para 6. 1st child from 2nd husband WHO CLASSIFICATION OF OBESITY : Overweight – BMI of ≥25 to 29.9 kg/m2. Obesity – BMI of ≥30 kg/m2. Obesity class 1 – BMI of 30 to 34.9 kg/m2. Obesity class 2 – BMI of 35 to 39.9 kg/m2. Obesity class 3 – BMI of ≥40 kg/m2. ( severe, extreme, or morbid obesity).
- 11. Intraoperative management Confirmedthe patient Connected to 3 lead ECG, pulse oximeter, NIBP BP- 120/80 mmHg PR – 100 bpm Spo2- 97 % RA Spinal anesthesia- Sitting/ midline / L4-5 luckily was able to palpate her spine easily 22 G quince needle injected 2 mL of 0.5% Heavy bupivacaine immediately after lA injection- pt lie down (supine)
- 12. Intra Op After10 minutes complained of nausea but no chest discomfort BP – 89/49 mmHg ( MAP - 53 mmHg) PR – 80 bpm Inj Ephedrine 18 mg IV bolus Inj Odansetron 4 mg IV bolus Thereafter uneventful surgery
- 13. Delivered babyboy APGAR – 9/10 Birth weight – 4.02 kg Blood loss – 1000 mL Fluid – 1 L of R/L
- 14. Post op Rightafter reaching in the ward complained of head ache Subsided with Diclofenac Na 75 mg IM Baby Feeding well LMWH 60 mg stat in the ward given and advised to give for 5 days However on Post Op Day 2 – stopped Discharged on day 3
- 15. Use of Anticoagulantin Surgery
- 16. Introduction The managementof anticoagulation in patients undergoing surgical procedures is challenging Interrupting - transiently increases the risk of thromboembolism. Surgery and invasive procedures have associated bleeding risks If the patient bleeds from the procedure, their anticoagulant may need to be discontinued for a longer period, resulting in a longer period of increased thromboembolic risk. A balance between reducing the risk of thromboembolism and preventing excessive bleeding must be reached for each patient.
- 17. Other issues vitaminK antagonist (eg, warfarin)- takes several days until the anticoagulant effect is reduced and then reestablished perioperatively The risks and benefits of "bridging" with a shorter acting agent, such as heparin, during this time are unclear. The newer direct oral anticoagulants (eg, direct thrombin inhibitor dabigatran, factor Xa inhibitors rivaroxaban, apixaban, edoxaban) have shorter half-lives, making them easier to discontinue and resume rapidly But the direct factor Xa inhibitors lack an approved drug- specific antidote,
- 18. approach shouldbe based on expert opinion thrombotic and bleeding risks may vary depending on individual circumstances, Data from randomized trials or well-designed observational studies are not available to guide practice in many settings. Thus, approach should be used as clinical guidance and should not substitute for clinician judgment in decisions about perioperative anticoagulant management for individual patients.
- 19. Decision should beon: Estimate thromboembolic risk Estimate bleeding risk Determine the timing of anticoagulant interruption Determine whether to use bridging anticoagulation
- 20. ESTIMATING THROMBOEMBOLIC RISK The major factors that increase thromboembolic risk are 1) Atrial fibrillation 2) Prosthetic heart valves 3) Recent venous or arterial thromboembolism (eg, within the preceding three months)
- 21. Atrial fibrillation Accountsfor the highest percentage of patients for whom perioperative anticoagulation questions arise. Importantly, patients with atrial fibrillation are a heterogeneous group Risk can be further classified according to clinical variables such as: age hypertension congestive heart failure diabetes prior stroke and other vascular disease The variables are incorporated CHA2DS2-VASc score
- 22. CHA2DS2-VASc score CHA2DS2-VASc riskfactor Points Congestive heart failureSigns/symptoms of heart failure or objective evidence of reduced left-ventricular ejection fraction +1 Hypertension-Resting blood pressure >140/90 mmHg on at least two occasions or current antihypertensive treatment +1 Age 75 years or older +2 Diabetes mellitusFasting glucose >125 mg/dL (7 mmol/L) or treatment with oral hypoglycaemic agent and/or insulin +1 Previous stroke, transient ischaemic attack, or thromboembolism +2 Vascular disease-Previous myocardial infarction, peripheral artery disease, or aortic plaque +1 Age 65-74 years +1 Sex category (female) +1 Note: use of risk scores has not been prospectively validated in the perioperative setting
- 23. Prosthetic heart valve Prosthetic valve who is undergoing an invasive procedure or surgery should take into account the type location number of prosthetic heart valves other risk factors for thromboembolism the type of procedure Since limited evidence is available, the recommendations presented are based largely on expert opinion
- 24. Standardized protocol(2012 AmericanCollege of Chest Physicians (ACCP) guidelines) Advance planning of perioperative anticoagulant management (including anticoagulant discontinuation and resumption and bridging therapy, as applicable), Providing patients and providers with a calendar outlining the timing of anticoagulant changes and INR testing Providing education on injection technique for any outpatient low molecular weight heparin (LMWH) therapy Assessment of postoperative hemostasis.
- 25. The riskof major bleeding with VKA begins to rise steeply when INR increases ≥5. However, in patients with mechanical valves who require interruption of VKA therapy, high-dose vitamin K should not be routinely administered before invasive procedures Since this will significantly delay the ability to re-anticoagulate with VKA after the procedure leading to subtherapeutic INRs, increases the risk of valve thrombosis and thromboembolism.
- 26. If theINR is ≥6 without bleeding, VKA should be stopped to permit a gradual reduction in INR small doses (1 or 2.5 mg) of oral vitamin K may be administered to hasten the fall in INR in patients with a high risk of bleeding. If the INR is >10 without bleeding, VKA should be discontinued and 1 to 2.5 mg of oral vitamin K should be administered, with frequent INR monitoring.
- 27. Avoid surgeryfor three months after valve surgery The risk of thromboembolism is highest in the first few months after mechanical or bioprosthetic mitral replacement or mitral valve repair
- 28. Recent thromboembolism Thromboembolicrisk is greater in the immediate period following a thromboembolic event and declines over time. Individuals with a recent thromboembolic event are likely to benefit from delaying surgery, if possible. If emergent surgery is required (eg, acute cholecystectomy), bridging anticoagulation may be used to reduce the interval without an anticoagulant.
- 29. Venous The perioperativerisk of venous thromboembolism is Greatest- in individuals with an event within the prior three months eg DVT, PE those with a history of VTE associated with a high-risk inherited thrombophilia. Moderate risk- Individuals with cancer low risk - Those with an event more than one year ago have Therefore, delaying elective surgery even if the delay is only for a few weeks will be beneficial. This approach is supported by data showing that the recurrence risk for individuals with a recent VTE is highest within the initial three to four weeks and diminishes over the following two months Without anticoagulation, the early risk of recurrent VTE was approximately 50 percent treatment with warfarin for one month reduced this risk to 8 to 10 percent after three months of warfarin therapy the risk declined to 4 to 5 percent
- 30. Arterial The riskof recurrent arterial embolism from any cardiac source is approximately 0.5 percent per day in the first month after an acute event. The vast majority of cases are due to atrial fibrillation Other less common cardiac sources include paradoxical embolism non-bacterial thrombotic endocarditis in a patient with malignancy dilated or poorly contractile left ventricle left ventricular aneurysm
- 31. Risk stratum Indication foranticoagulant therapy Mechanical heart valve Atrial fibrillation VTE Very high thrombotic risk* Any mitral valve prosthesis Any caged-ball or tilting disc aortic valve prosthesis Recent (within six months) stroke or transient ischemic attack CHA2DS2-VASc score of ≥6 (or CHADS2 score of 5-6) Recent (within three months) stroke or transient ischemic attack Rheumatic valvular heart disease Recent (within three months) VTE Severe thrombophilia (eg, deficiency of protein C, protein S, or antithrombin; antiphospholipid antibodies; multiple abnormalities) High thrombotic risk Bileaflet aortic valve prosthesis and one or more of the of following risk factors: atrial fibrillation, prior stroke or transient ischemic attack, hypertension, diabetes, congestive heart failure, age >75 years CHA2DS2-VASc score of 4-5 or CHADS2 score of 3-4 VTE within the past 3 to 12 months Nonsevere thrombophilia (eg, heterozygous factor V Leiden or prothrombin gene mutation) Recurrent VTE Active cancer (treated within six months or palliative) Moderate thrombotic risk Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke CHA2DS2-VASc score of 2-3 or CHADS2 score of 0-2 (assuming no prior stroke or transient ischemic attack) VTE >12 months previous and no other risk factors
- 32. ESTIMATING PROCEDURAL BLEEDINGRISK As a general guideline, procedures are divided into high and low bleeding risk (2 day risk of major bleeding 2 to 4 percent or 0 to 2 percent, respectively) High bleeding risk procedures include coronary artery bypass surgery kidney biopsy any procedure lasting >45 minutes low bleeding risk procedures include cholecystectomy, carpal tunnel repair abdominal hysterectomy Dental and cutaneous procedures
- 33. DECIDING WHETHER TOINTERRUPT ANTICOAGULATION Limited Data Decisions that balance thromboembolic and bleeding risks must be made on a case-by-case basis. In general, the anticoagulant must be discontinued if the surgical bleeding risk is high. Those at very high or high thromboembolic risk should limit the period without anticoagulation to the shortest possible interval In contrast, individuals undergoing selected low bleeding risk surgery often can continue their anticoagulant
- 34. Settings requiring anticoagulant interruption Individuals with a temporarily very high or high thromboembolic risk in whom surgery cannot be delayed (eg, potentially curative cancer surgery in a patient who just had an acute VTE) For individuals with a chronically elevated thromboembolic risk Individuals with a moderate thromboembolic risk - can interrupt without bridging Temporary interruption of anticoagulation for a minor procedure such as central venous catheter placement
- 35. Settings in whichcontinuing the anticoagulant may be preferable Dental procedures – (An exception is multiple tooth extractions, which we consider high bleeding risk). Cutaneous procedures - skin biopsy, tumor excision Selected cardiac procedures Cardiac implantable devices Endovascular procedures and catheter ablation
- 36. TIMING OF ANTICOAGULANTINTERRUPTION Warfarin (VKA, PT/INR) discontinue warfarin 5 days before elective surgery (ie,last dose of warfarin is given on day minus 6) biological half-life -36 to 42 hours check the PT/INR on the day before surgery If the INR is >1.5, we administer low dose oral vit K (eg, 1 to 2 mg) and recheck the following day. when the INR is ≤1.4 - proceed with surgery
- 37. LMWH shouldbe discontinued at least 24 hours If a twice-daily LMW heparin regimen - the evening dose the night before surgery is omitted If a once-daily regimen - one-half of the total daily dose is given on the morning of the day before surgery. Unfractionated heparin –IV infusion until four to five hours before the procedure If S/C, the last dose can be given the evening before the procedure.
- 38. Dabigatran – 2-3 days with normal or mildly impaired renal function (ie, creatinine clearance >50 mL/minute), 2-4 days in those with more severe renal insufficiency (eg, creatinine clearance between 30 and 50 mL/minute) Rivaroxaban - 2-3 days Apixaban - 2-3 days Edoxaban- 2-3 days Clopidogrel 7 days Acetylsalicylic acid(Aspirin) – can continue
- 39. BRIDGING ANTICOAGULATION Involvesthe administration of a short-acting anticoagulant LMW heparin or Unfractionated heparin Aim - to minimize the time the patient is not anticoagulated, thereby minimizing the risk for perioperative thromboembolism High thromboembolic risk with prolonged interruption of their anticoagulant [VKA])
- 40. Need of bridgingin individuals taking warfarin for one of the following conditions: Embolic stroke or systemic embolic event within the previous three months Mechanical mitral valve Mechanical aortic valve and additional stroke risk factors Atrial fibrillation and very high risk of stroke (eg, CHADS2 score of 5 or 6, stroke or systemic embolism within the previous 12 weeks) VTE within the previous three months (preoperative and postoperative bridging) Recent coronary stenting (eg, within the previous 12 weeks) Previous thromboembolism during interruption of chronic anticoagulation
- 41. Postoperative timing ofbridging Postoperative resumption of unfractionated heparin and LMW heparin is similar. The resumption of bridging will vary depending on the surgery type and individual patient considerations For those undergoing major surgery or those with a high bleeding risk procedure - should be delayed for 48 to 72 hours after hemostasis has been secured. For most minor procedures associated with a low bleeding - resume 24 hours after the procedure.
- 42. URGENT/EMERGENT INVASIVE PROCEDURE Warfarin If semi-urgent (eg, within one to two days),- warfarin should be withheld and vitamin K administered (eg, 2.5 to 5.0 mg of oral or intravenous). If immediate reversal - prothrombin complex concentrates (PCCs) or plasma products (eg, Fresh Frozen Plasma [FFP], thrombotic risk associated with these products used only if there is life-threatening bleeding and prolongation of the INR by a vitamin K antagonist
- 43. NEURAXIAL ANESTHESIA Shouldnot be used in anticoagulated individuals risk of potentially catastrophic bleeding into the epidural space(both at the time of catheter placement and the time of removal). The timing of anticoagulant use in patients receiving neuraxial anesthesia is illustrated by evidence-based guidelines from the American Society of Regional Anesthesia (ASRA), which suggest the following : Prophylactic dose LMW heparin (eg, enoxaparin 40 mg once daily): Before surgery, wait at least 10 to 12 hours after the last dose of LMW heparin is administered before a spinal/epidural catheter is placed. After surgery, when there is adequate surgical site hemostasis, wait at least six to eight hours after catheter removal before resuming treatment with LMW heparins.
- 44. Therapeutic doseLMW heparin (eg, enoxaparin, 1 mg/kg twice daily): Before surgery, wait at least 24 hours after the last dose of LMW heparin is administered before a spinal/epidural catheter is placed. After surgery, when there is adequate surgical site hemostasis, for twice daily dosing, wait at least 24 hours after catheter removal before resuming therapeutic-dose LMW heparin. For once daily dosing, wait at least six to eight hours after catheter removal before the first dose;
- 45. Length of therapy The optimal duration of anticoagulation is unknown should be individualized on a case-by-case basis. However, based upon extrapolated data from the general population as well as clinical experience, the total duration of anticoagulant therapy (pregnancy plus the postpartum period) should be at least three to six months for women whose only risk factors for VTE were transient (eg, pregnancy, cesarean section) Anticoagulant therapy generally continues for at least six weeks postpartum. Patients with persistent risk factors for VTE may require a longer duration of therapy.
- 46. American Society ofRegional Anesthesia and Pain Medicine, Number 3, April 2018 Perioperative Management of Patients on Warfarin: Preoperative Discontinue warfarin at least 5 days before elective procedure Assess INR 1–2 d prior to surgery, if >1.5, consider 1–2 mg oral vitamin K Reversal for urgent surgery/procedure, consider 2.5–5 mg oral or IV vitamin K; for immediate reversal, consider PCCs, fresh frozen plasma Patients at high risk of thromboembolism ○ Bridge with therapeutic SC LMWH (preferred) or IV UFH ○ Last dose of preoperative LMWH administered 24 h before surgery, administer half of the daily dose ○ Intravenous heparin discontinued 4–6 h before surgery No bridging necessary for patients at low risk of thromboembolism
- 47. Postoperative Patientsat low risk of thromboembolism ○ Resume warfarin on POD Patients at high risk of thromboembolism (who received preoperative bridging therapy) ○ Minor surgical procedure—resume therapeutic LMWH 24 h postoperatively ○ Major surgical procedure—resume therapeutic LMWH 48–72 h postoperatively or administer low-dose LMWH Assess bleeding risk and adequacy of hemostasis when considering timing of the resumption of LMWH or UFH therapy
- 48. Perioperative Management ofPatients on Antiplatelet Therapy Patients with coronary stents • Elective surgery postponed for the following durations if aspirin and thienopyridine (eg, clopidogrel or prasugrel) therapy must be discontinued ○ Bare metal stents: 6 wk ○ Drug-eluting stents: 6 mo • If surgery cannot be postponed, continue dual antiplatelet therapy throughout perioperative period
- 49. Patients athigh risk of cardiac events (exclusive of coronary stents) • Continue aspirin throughout the perioperative period • Discontinue clopidogrel/prasugrel 5 d prior to surgery • Resume thienopyridine 24 h postoperatively patients at low risk of cardiac events • Discontinue dual antiplatelet therapy 7–10 d prior to surgery • Resume antiplatelet therapy 24 h postoperatively
- 50.