durner l.,bourdoumis a., masood j., buchholz n. royal london hospital, bartshealth nhs trust royal...

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  • DURNER L.,BOURDOUMIS A., MASOOD J., BUCHHOLZ N.

    ROYAL LONDON HOSPITAL, BARTSHEALTH NHS TRUSTROYAL DEVON AND EXETER NHS TRUSTHOMERTON UNIVERSITIY HOSPITAL NHS TRUST

    Handling thromboprophylaxis minimally invasive stone procedures

  • Introductionmultiple co-morbiditiescardiology procedures get more complexAntiplatelets Anticoagulationcronic bleeding disorder

    peri- and post- operative thromboprophylaxislow / intermediate / high risk

  • Purposecurrent evidence practical guide for thromboprophylaxisdosing and duration modifications anticoagulation regimens dependent on planned procedure

  • Materials and Methodssystematic review and evidence-based research of the literature.

    Key words: anticoagulation treatment, antiplatelet agents, stone surgery, lithotripsy, perioperative thromboprophylaxis, perioperative bridging therapy and coagulopathy, alone or in combination.

    Evidence synthesis and creation of a management protocol.

  • The rationale.....

    Appropriate indication for stone treatment modality

    Appropriate patient selection (dont be a hero...)Risk of thrombosisRisk of bleeding

  • Arterial thromboembolismVenous thromboembolismMechanical heart valves (risk of arterial thrombosis (CVAs, INR < 2)

    High risk group (> 10%/year) Patients with mechanical heart valves, especially mitral valve or one of the older generation aortic valves (caged-ball, tilting-disk), and also patients suffering from ischemic stroke or transient ischemic attack within the last 6 months.

    Intermediate risk group (4-10%/year) Patients with a bileaflet aortic valve and one or more of the following: atrial fibrillation, history of ischemic stroke or transient ischemic attack, hypertension, diabetes, age >75 years and congestive heart failure.

    Low risk group ( 10%/year) Recent episode of DVT/PE (< 3 months), hereditary thrombophilia (Protein S or C deficiency, antithrombin deficiency, homozygotes for Factor V Leiden and G20210A prothrombin gene mutation), antiphospholipid syndrome and active cancer . Intermediate risk group (5-10%/year) Patients with history of DVT/PE between 3-12 months, heterozygotes for Factor V Leiden and prothrombin gene mutation and patients with previous malignancy.

    Low risk group (

  • ConclusionsThe regulation of anticoagulation treatment and the relative risk of thromboembolic events ultimately rest with the operating surgeon in collaboration with the anesthesiology / cardiology / hematology specialists when required.

    Ureteroscopy is favored in anticoagulated patients, always with respect to stone size and location.

    Shock wave lithotripsy and PCNL is a form of stone treatment, with strict adherence to bridging protocols and patient risk factors required in most cases.

    Patients with cardiovascular stents constitute a unique risk group and specialist input should always be sought.

  • Questions-DiscussionThank you for your attention

    Douketis JD, Spyropoulos AC, Spencer FA, et al. American College of Chest Physicians. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 141 (2 Suppl):e326S-50S (2012). Thromboprophylaxis and bleeding diathesis in minimally invasive stone surgery. Bourdoumis A, Stasinou T, Kachrilas S, Papatsoris AG, Buchholz N, Masood J. Nat Rev Urol. 2014 Jan;11(1):51-8.

  • IntroductionThe urologist frequently encounters patients with multiple and complex co-morbidities, who are on regular antiplatelet or anticoagulation medication or suffering from a chronic bleeding disorder.

    Decisions regarding peri- and post- operative thromboprophylaxis in urological surgery patients and stone surgery patients in particular are frequently met with confusion.

  • The evidence.... - for stones -increased bleeding risk during perioperative antithrombotic drug administration, probably due to urokinase release All lithotripsy options except ureteroscopy are contraindicated in the face of uncorrected bleeding tendency SWL and ureteroscopy performed as day case appear to have very low risk of thromboembolismPCNL and complicated ureteroscopy (prolonged operating time, impacted stone, large stone burden) carry an intermediate risk for thromboembolic events

  • The evidence....- for anticoagulants -day case procedures do not usually require pharmacological thromboprophylaxis.Patients with inherent or acquired risk factors anticoagulation for 10dIn low risk for thromboembolism, no bridging of anticoagulation during interruption of warfarin (LE: 2c) Aspirin may be continued up to the time of surgery instead of stopping 7 to 10 days before (LE: 2c)

    According to the annual incidence of thrombotic events*

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