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- 1. Peri-operative anticoagulation Dr. Mustafa Bayoumi “Clinical fellow in trauma and orthopedics- ST1” Dr. Wong Orthogeriatric consultant
- 3. Thrombosis is the formation of a blood clot, known as a thrombus, within a blood vessel. It prevents blood from flowing normally through the circulatory system.
- 6. Leading cause of death in western countries
- 7. what stops you from bleeding when you hurt yourself? In a healthy body, blood clots play an important role in this. At the site of a cut, blood platelets and red blood cells are held together by a rope-like molecule called fibrin. This forms a blood clot, which plugs up the cut and stops bleeding. This is an important process. it can, however; cause major health issues when it happens at the wrong time.
- 8. When a blood clot forms in the veins, it is known as venous thromboembolism. This can cause deep vein thrombosis and pulmonary embolisms. When a clot forms in the arteries, it is called atherothrombosis, which can lead to heart attack and stroke.
- 14. It's a rare kind of DVT that typically happens to a young, healthy person who plays sports that use the upper arms a lot, like swimming and baseball. The vein can get squeezed by the muscles around it. This pressure, along with repeated movements, can cause a clot in your shoulder. Symptoms like swelling, chest pain, and a blue color to your skin may come on suddenly. PSS can be serious if it's not treated right away.
- 18. CHAD score vs chad vasc?
- 20. What is the has bled score? HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation. ... Major bleeding is defined as being intracranial bleedings, hospitalization, hemoglobin decrease > 2 g/dL, and/or transfusion
- 22. Procedural bleeding risk Low / major bleed risk 1.5% Diagnostic procedure eg endoscopy, angiography Dental procedures Minor ortho surgeries: hands/ feet/ shoulder High Major risk >1.5 Body cavity surgery eg intracrania/spinal/ocular >45 mins surgeries are major surgeries Urological/ laprascopic surgeries Surgery in highly vascular organ
- 25. What's factor I What's factor 2? Factor 6 ? Factor 4 ?
- 27. How Do we anticoagulate?
- 32. Q/ a situation where heparin wont be effective?
- 33. Child with nephrotic syndrome?.. Losing anti thrombin enzyme you would actually give them heparin plus FFP to get heparin a substance to act on and therefore be effective
- 34. The Warfarin
- 36. NB: warfarin inhibits 1972 +proties C & S Protien C is anticoagulant Warfarin acts as a pro-coagulant initially? Need for heparin on initation ttt with VKA
- 37. Warfarin initial action as a procoagulant can lead to warfarin induced skin necrosis
- 38. Hirudin derived direct thrombin inhibitors Dabigtran argatroban
- 41. the Xa’s… NOAC’s Rivaroxaoban Edoxaban etc…
- 45. VIT k as an antidote?? .. All or non effect in terms of reversing warfarin effect. Hard to titrae? /VIT k overdose.. Some one with a heart valve? Thrombosis/ procoagulant state
- 46. FFP on the other hand allows you to” gradually sneak your way up? In terms of homeostasis instead of all or non effect .. Aka “slamming the door”
- 47. Protamine.. Positively charged molecule that attracts heparin ( large molecule with negative charge)
- 48. Noacs causing major bleeding..?
- 50. What anticoagulation Cancer patients should be on?
- 54. Bridging guildines MMG086 Periprocedural (perioperative) management of already anticoagulated patients
- 56. Topic to read on How to treat some one with major bleeding and is on NOACs?
- 57. Questions?
- 58. Factors that contribute to increased risk of VTE while flying/travelling Higher risk of venous thrombo- embolism Prolonged immobilization Cramped sitting position Dehydration Low cabin humidity/ low oxygen
- 59. All elective surgeries? Elective surgeries with higher VTE risk General anathesia lasting > 30 minutes Operations that lead to significant immobility Vascular disruptions incluind the use of a tourniquet Cancer or suspected cancer patients
- 61. Flying after high risk elective surgeries : time frame <4 weeks (or <3 months in LL orthopedic surgeries) • Significant high risk of developing VTE • Advise against flying/ if unavoidable VTE prevention as per NICE guidelines 4-8 weeks post surgery • Slightly high risk • VTE prevention as per NICE guidelines >8 weeks • Low risk of VTE • General advise ( detailed later)
- 62. Moderate-Major lower limb surgeries = Higher risk 1 • Major joint arthroplasty 2 • Ankle fusion 3 • Tendon reconstruction
- 63. Coach or car journey > 6 hours = Long flight in Aeroplanes for 4 hours or more
- 64. Avoid prolonged immobility Maintain normal fluid intake Avoid excessive alchol as it leads to dehydration and inertia Wear appropriate compression stockings unless contraindictaed To seek urgent medical advice if you develop swollen painful legs or SOB
- 65. General advice for the patients post operatively to prevent VTE
- 66. Unavoidable surgery following a prolonged flight? Well’s score can help doctors assess a patient's risk for VTE especially if presenting for emergency / or elective surgery right after a flight over 4 hours within the preceding 4 weeks. Or even presenting after 3-4 hours flights within the preceding two weeks. The score can aid in the decision whether to postpone the surgery or to carry on with it
- 68. Flights > 4 hours Score0 surgery to be delayed for at least 2 weeks post flight . If unavoidable, then: 1-Compression stocking for 4 weeks +/- pharmacological thrombo-prophylaxis if immobile at home Score1 surgery to be delayed for at least 2 weeks post flight . If unavoidable then: 1- compression stockings for 6 weeks post operatively 2-If there is immobility at home pharmacological thrombo-prophylaxis Score>2 surgery to be delayed for at least 4 weeks post flight. If unavoidable then: 1- compression stockings for 6 weeks post operatively 2-Discuss with a hemtaologist pharmacological thrombo-prophylaxis
- 69. Special considerations Withold the pill until six weeks after surgery To be offered/ advised on alternative contraceptive measures. OCOCP Bridging anticoagulation to be discussed with hematology Long term anticoagulation
- 70. If travelling is unavoidable Moderate risk patients General advice on DVT prevention Use of well fitted graduated compression stockings/obtain adequate medical travel insurance before travelling. High risk patients As for moderate risk patients Seek specialist advice from a hematologist regarding whether the use of LMWH is indicated.
- 72. Aspirin There is good evidence that aspirin is useful in preventing arterial thrombosis, but it is not recommended for the prevention of venous thrombosis during travel. Aspirin does not reduce VTE in high risk patients [11, 17]. Furthermore a Cochrane review noted that approximately one patient in 40 taking low dose aspirin develop gastric irritation [18]. Due to insufficient evidence supporting the use of aspirin in travel related venous thrombosis, guidelines from the American College of Chest Physicians recommend against its use for VTE prevention associated with travel [6]. UK guidelines support the view that aspirin should not be used for the prevention of VTE in hospital patients [7] or travellers [8].
- 73. https://www.cochranelibrary.com/ cdsr/doi/10.1002/14651858.CD00 4002.pub3/full Authors' conclusions There is high‐quality evidence that airline passengers similar to those in this review can expect a substantial reduction in the incidence of symptomless DVT and low‐quality evidence that leg oedema is reduced if they wear compression stockings. Quality was limited by the way that oedema was measured. There is moderate‐quality evidence that superficial vein thrombosis may be reduced if passengers wear compression stockings. We cannot assess the effect of wearing stockings on death, pulmonary embolism or symptomatic DVT because no such events occurred in these trials. Randomised trials to assess these outcomes would need to include a very large number of people.
- 74. The risk of venous thromboembolism (VTE) for most travellers is low. For a flight > 4 hours, in healthy individuals, the risk is estimated to be 1 in 6,000. The risk increases with longer duration of travel and with multiple flights within a short period. The risk of pulmonary embolism is much lower.
- 75. https://www.ncbi.nlm.nih.gov/pmc /articles/PMC6272050/ 7. Conclusion Clinical data on VTE prophylaxis for travel-related VTE are still rather limited. Physicians must balance between risks of thrombosis and bleeding in an individual patient. Consideration on the patient’s risk score and traveling schedule is helpful. Current clinical trial data suggest that DOACs can be used to treat travel-related VTE. Although the direct clinical data for primary prophylaxis is lacking, there is no rationale to suggest that DOACs are not effective in this indication.