perioperative management of anticoagulation

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PerioperativeManagement of

Antithrombotic Therapy

ACCP Guidelines. CHEST !"#"$"%&'e()S*

+!S,-/GE Trial. 0 Engl 1 Med !"+#(2('3(*((



4TE -S5 Patient factors

Anticoagulation regimenComorbidities

VTE (1%/d, 40% 1m, 10% 2!m, "% #!m$ &it' AC of 0%Arterial emboli (0)"%/d, 1"% 1m* A+b # 1

12%/ as -er score$ &it' AC of ..%

Prost'etic 'eart ale (ec'anical 22%/,##A$

&it' AC of "%VTE (.% fatal, 2% disabilit$, tro3e (20% fatal, 40%

disabilit$

Perioperative Mgmt' ,alancing Act

Engl 5 166*!!.71"0.11



,6EE/0G -S5 Patient factors

Anticoagulation regimen8rug, intensit, duration, stabilit

ComorbiditiesAge, lier disease, renal disease, clotting disorders* ot'er drugs

urgical factors

5o'ns 9o-3ins urgical

:leeding Classi+cationE:;7 inimal, <"00ml,

"001000, #1"00!% fatal* "0% anot'er -rocedure* 1% disabilit

Perioperative Mgmt' ,alancing Act

Engl 5 166*!!.71"0.11



7A-8A-0Same day' $*PCC 9 4it5 40e:t day' 4it5 P;

/A,GAT-A0

"*"2hdaruci<umab %Pra:bind& * approved

=a 0H,T;-S-ivaro:aban > +*?hApi:aban > 3*"+hEdo:aban > )*""hAnde:anet alfa@ P-T!)$$$+ > not 8/A approvedPE-?22# Perosphere > not 8/A approved@ also for dabigatran and 6M7HAntibrinolytic agents %trane:amic acid@ epsilon*aminocaproic acid&

Perioperative Mgmt' Brgent Surgery

Engl 5 ed 2014* !172141) Engl 5 ed 201"*



Perioperative Mgmt' 4TE -is >Mechanical 4alve

HGH -S5 An mitral ale -rost'esis =lder (cagedball or tilting disc$ aortic ale -rost'esisecent (&it'in . mont's$ stro3e or T>A

M;/E-ATE -S5 :ilea?et aortic ale and at least one of7Atrial +brillation, -rior stro3e or transient isc'emic

attac3, '-ertension, diabetes, congestie 'eartfailure, age #" ears

6;7 -S5 :ilea?et aortic ale &it'out atrial +brillation and noot'er ris3 factors for stro3e



Perioperative Mgmt' 4TE -is > A8ib

HGH -S5 C9A82 score @ ".

ecent (&it'in ! mont's$ stro3e or T>A 'eumatic alular 'eart disease

M;/E-ATE -S5 C9A82 score @ !4

6;7 -S5 C9A82 score @ 02 and no -rior stro3e or T>A



Perioperative Mgmt' 4TE -is > 4TE

HGH -S5 ecent VTE (<! mont's ago$eere t'rombo-'ilia (eg, anti-'os-'oli-id

antibodies$

M;/E-ATE -S5 VTE &it'in t'e -ast !12 mont's onseere t'rombo-'ilia (eg, 'eterogous factor Vmutation$ ecurrent VTE

Actie cancer (treated &it'in . mont's or -alliatie$

6;7 -S5 Prior VTE #12 mont's ago and no ot'er ris3 factors



Perioperative Mgmt' ,leeding ris

CC5 2006*.7!44



Perioperative Mgmt' ,leeding ris

HGH -S5 Brologic surger/-rocedures7 TBP, bladder resection or tumorablation, ne-'rectom or 3idne bio-s (untreated tissuedamage after TBP and endogenous uro3inase release$

Pacema3er or >C8 im-lantation (se-aration of infraclaicularfascia and no suturing of uno--osed tissues ma lead to'ematoma$

Colonic -ol- resection, es-eciall #12 cm sessile -ol-s(bleeding occurs at transected stal3 after 'emostatic -lugrelease$

Vascular organ surger7 t'roid, lier, s-leen

:o&el resection (bleeding ma occur at anastomosis site$

aor surger inoling considerable tissue inur7 cancersurger, oint art'ro-last, reconstructie -lastic surger

Cardiac, intracranial or s-inal surger (small bleeds can 'aeserious clinical conseDuences$



A )3*year*old Doman receiving

chronic Darfarin for recurrent /4T

%most recent Das " year ago& Dillundergo tDo dental e:tractions that

Dill include local anesthetic

inectionsF

Case 4ignette 0o. "



". Stop Darfarin at day *+ before

procedure@ give therapeutic*dosebridging Dith 6M7H %eg@ eno:aparin@ "mgg bid&

. Continue Darfarin Dithout dosereduction and give prohemostaticmouthDash %cycloapron& aroundprocedure

(. Continue Darfarin Dithout dosereduction

$. Stop Darfarin days before procedureand resume after procedure

Management ;ptions



Patients -euiring MinorProcedures

• n patients Dho reuire minor dental surgery

and are receiving 45A therapy@ De suggesteither continuing 45A Dith co*administration ofan oral prohemostatic agent or stopping 45As*( days before the procedure instead of alternative strategies %Grade C&.

• n patients Dho reuire minor sin proceduresand are receiving 45A therapy@ De suggestcontinuing 45As around the time of theprocedure and optimi<ing local hemostasis

instead of other strategies %Grade C&.

• n patients Dho reuire cataract surgery andare receiving 45A therapy@ De suggestcontinuing 45As around the time of the surgery

instead of other strategies %Grade C&.



A +$*year*old man Dith amechanical mitral valvereplacement on long*term Darfarintherapy is scheduled for total hipreplacementF

Case 4ignette 0o.



". Stop Darfarin + days preop@ administer

therapeutic*dose bridging Dith 6M7H%eg@ eno:aparin@ " mgg bid& preop andpostop

. Stop Darfarin + days preop@ administerloD*dose 6M7H preop and postop %eg@dalteparin@ +!!! B I/&

(. Continue Darfarin but reduce dose by+!J starting + days preop

$. Stop Darfarin + days preop and resumeafter procedure

Management ;ptions



Patients at High -is having MaorSurgery

• n patients Dho reuire temporary interruption

of a 45A before surgery@ De recommendstopping 45As appro:imately + days beforesurgery instead of stopping 45As a shortertime before surgery %Grade "C&.

•

n patients Dho reuire temporary interruptionof a 45A before surgery@ De recommendresuming 45As appro:imately "*$ hrs aftersurgery %evening of or ne:t morning& and Dhenthere is adeuate hemostasis instead of later

resumption of 45As %Grade C&.

• n patients Dith a mechanical heart valve@ atrialbrillation or 4TE at high ris for TE@ Desuggest bridging anticoagulation instead of no

bridging during interruption of 45A therapy



Perioperative Administration of,ridging

• n patients Dho are receiving bridging

anticoagulation Dith therapeutic*dose SC6M7H@ De suggest administering the lastpreoperative dose of 6M7H appro:imately $ hbefore surgery instead of " h before surgery

%Grade C&.

• n patients Dho are receiving bridginganticoagulation Dith therapeutic*dose SC6M7H and are undergoing high bleeding*ris

surgery@ De suggest resuming therapeutic*dose6M7H $3*2 h after surgery instead of resuming 6M7H Dithin $ h after surgery%Grade C&.



A )?*year*old man Dith chronicatrial brillation and hypertension%CHA/S score L "& is undergoing a

abdominal surgery for cancerF

Case 4ignette 0o. (



". Stop Darfarin + days preop@ administer

therapeutic*dose bridging Dith 6M7H%eg@ eno:aparin@ " mgg bid& preop andpostop

. Stop Darfarin + days preop@ administerloD*dose 6M7H preop and postop %eg.@daltearin@ +!!! B d&

(. Continue Darfarin but reduce dose by+!J starting + days preop

$. Stop Darfarin + days preop and resumeafter procedure

Management ;ptions



Patients at 6oD -is for TE HavingMaor Surgery

• n patients Dith a mechanical heart valve@ atrialbrillation or 4TE at loD*ris for TE@ De suggestno bridging instead of bridging anticoagulationduring interruption of 45A therapy %Grade C&.



,-/GE Trial



,-/GE Trial > Critiue

• mall number &it' mitral stenosis (< 2%$ or 'ig'ris3 nonalular AF (< 14% 'ad C9A82score G 4$

• About 60% of t'e -rocedures &ere minor (includingendosco-ies, cardiac cat'eteriations, dental-rocedures, and minor dermatologic and ort'o-edic

-rocedures, &'ic' com-rised about "% of t'e totalminor surgeries$)

• = bridging strateg for lo&erris3 AF and minor-rocedures)

• abe &ait for PE>=P2 trial before sto--ingbridging in 'ig'ris3 -atients)



M5SAP• " is seen for -reo- ealuation -rior to umbilical 'ernia

re-air in 1&3) 9e 'as increasing -ain at t'e site of 'is

umbilical 'ernia, but no incarceration) 9e eHercisesregularl &it'out sm-toms) o '/o stro3e or transientisc'emic attac3) edical 'istor is notable for aorticale re-lacement &it' bilea?et mec'anical -rost'esis-erformed ! ears ago for a bicus-id aortic ale and

decreasing eHercise ca-acit) edications are &arfarinand lo&dose as-irin)

• =n eHamination, :P 124/2, 9 0/min) CardioasculareHamination reeals a regular r't'm, a mec'anical 2,and a grade 1/. earl sstolic crescendodecrescendomurmur at t'e cardiac base &it'out radiation) ;aboratorstudies s'o& a normal serum creatinine leel) ECI-erformed 2m ago s'o&ed ) An EC9= 2m ago

s'o&ed normal ;VEF and normal function of t'emec'anical aortic ale -rost'esis)



M5SAP

>n addition to continuing as-irin and sto--ing &arfarin" das before surger, &'ic' of t'e follo&ing is t'e

most a--ro-riate management for -reo-eratieanticoagulation bridgingJ

A) >V unfractionated 'e-arin

:) Pro-'lacticdose subcutaneous enoHa-arin

C) T'era-euticdose subcutaneous enoHa-arin

8) o bridging anticoagulation



CHEST Guideline. CHEST !")# "$?%&'("+*

+



Antithrombotic Therapy for 4TE• For VTE and no cancer, as longterm AC t'era-, &e suggest

dabigatran (Irade 2:$, riaroHaban (Irade 2:$, a-iHaban (Irade 2:$,or edoHaban (Irade 2:$ oer itamin K antagonist (VKA$ t'era-, andsuggest VKA t'era- oer lo&molecular&eig't 'e-arin (;L9*Irade 2C$)

• For VTE and cancer, &e suggest ;L9 oer VKA (Irade 2:$,dabigatran (Irade 2C$, riaroHaban (Irade 2C$, a-iHaban (Irade 2C$,

or edoHaban (Irade 2C$)

• For VTE treated &it' AC, &e recommend against an >VC +lter (Irade1:$)

• For 8VT, &e suggest not using com-ression stoc3ings routinel to

-reent PT (Irade 2:$)

• For subsegmental PE and no -roHimal 8VT, &e suggest clinicalsureillance oer anticoagulation &it' a lo& ris3 of recurrent VTE(Irade 2C$, and anticoagulation oer clinical sureillance &it' a 'ig'ris3 (Irade 2C$)

perioperative management of anticoagulation

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