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ANTI-COAGULANTS: Surgical Perspective PowerPoint Presentation

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Description : Check out this medical presentation on Anticoagulant, which is titled "ANTI-COAGULANTS: Surgical Perspective", to know how patients with underlying cardiovascular disease require long-term anticoagulation.

Tags : Anticoagulant, ANTI-COAGULANTS, Surgical Perspective, cardiovascular disease, anticoagulation

Published on : May 25, 2021 | Views : 2015 | Downloads : 1

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Slide 1-

ANTI-COAGULANTS: Surgical Perspective
Slide 2-

Many patients with underlying cardiovascular disease require long-term anticoagulation. The perioperative or periprocedural management of patients who require temporary interruption of anticoagulant or antiplatelet medications is a common and often challenging clinical problem.
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Interruption of anticoagulation is associated with an increased risk of thromboembolic events such as stroke, mechanical valve thrombosis, stent thrombosis, and venous thromboembolism (VTE).
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ANTICOAGULANTS
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LOW BLEEDING RISK The American Society of Gastrointestinal Endoscopy divided endoscopic procedures into low and high risk Low bleeding-risk endoscopic procedures do not require a change in anticoagulation. Upper endoscopy with or without biopsy Flexible sigmoidoscopy with or without biopsy Colonoscopy with or without biopsy Endoscopic retrograde cannulation of the pancreatic duct without sphincterotomy
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Biliary stent insertion without sphincterotomy Endosonography without fine-needle aspiration
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HIGH BLEEDING RISK Polypectomy Laser ablation and coagulation Endoscopic sphincterotomy Pneumatic or bougie dilation Percutaneous endoscopic gastrostomy tube placement Treatment of varices
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BRIDGING Bridging anticoagulation, though frequently recommended, can increase the risk of perioperative bleeding (Arch Intern Med 2008;168:6). Resumption of bridging therapy within 24 hours is probably safe for minor procedures. For patients undergoing major surgery, restarting bridging therapy within 24 hours of surgery is associated with unacceptably high bleeding rates (J Thromb Haemost 2007;5:2211 ).
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One option is to delay restarting bridging until 48 to 72 hours postoperatively. A second option is to resume the VKA postoperatively within 12 to 24 hours as above and forego bridging postoperatively
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Choices for bridging therapy are generally the LMWHs and UFH. There is less experience with other agents (e.g., fondaparinux), and their use cannot be considered routine. LMWHs have the advantages of relatively predictable pharmacokinetics in patients with normal renal function and ability to be administered subcutaneously. Monitoring of anticoagulant effect is typically not required.
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The effect of LMWH can linger if a therapeutic anticoagulation dose is given <1 day prior to surgery (Ann Intern Med 2007;146:184 ). Thus, the last dose should be given 24 hours prior to surgery. UFH can be used in patients with renal disease, but typically it must be administered IV and requires frequent monitoring of the aPTT, necessitating hospitalization. UFH should be stopped 4 hours prior to the planned surgical procedure to allow the anticoagulant effect to wane.
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Patients at high risk of thromboembolic events should typically be treated with bridging therapy. Full-dose LMWH is recommended over UFH, though either is acceptable. Though the ACCP recommendation is evidence based, it should be noted that the older ACC/AHA guidelines on management of valvular disease continue to recommend IV UFH for bridging in patients with prosthetic valves (Circulation 2006;114:e84 )
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For patients at moderate risk of thromboembolic events, treatment with bridging is recommended, but options other than full anticoagulation are optional. Therapeutic anticoagulation with LMWH or UFH (as for high-risk patients) is preferred, but treatment with DVT prophylaxis dosing of LMWH is considered an acceptable alternative.
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Patients at low risk for thromboembolism are not felt to require bridging therapy. Treatment with DVT prophylaxis doses of LMWH is an alternative.
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Acute gastro-intestinal haemorrhage in patients on anticoagulant or antiplatelet agents is a high-risk situation. The immediate risk to the patient from haemorrhage may outweigh the risk of thrombosis as a result of stopping anticoagulant or antiplatelet therapy. Patients need to be assessed on an individual basis. For patients with high-risk conditions on warfarin, then this can be discontinued with or without substitution of heparin depending on the severity of haemorrhage and risk of discontinuing anticoagulant therapy.
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There is a high risk of acute myocardial infarction or death if clopidogrel is discontinued in patients with coronary stents, particularly early after implantation, but extending up to 1 year after this.
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Endoscopy should be attempted as soon as safely possible after urgent liaison between the patient’s cardiologist and the consultant specialist undertaking endoscopy. Clopidogrel should not be discontinued without discussion with a cardiologist. If clopidogrel therapy needs to be discontinued in this context, then this should be limited to a maximum of 5 days as the risk of stent thrombosis increases after this interval. Early therapeutic endoscopic intervention may achieve haemostasis with minimal or no cessation of anticoagulant or antiplatelet therapy, and should be the first aim. (Evidence grade IV. Recommendation grade C.)
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WARFARIN VS NOA
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Standard bleeding risk procedures(including colonoscopy, laparoscopic procedures, and any aspirations not involving the spinal canal) in patients with normal CrCl (50 mL/min), dabigatran use should be stopped at least 48 hours before the procedure. Rivaroxaban and apixaban use should be stopped at least 24 hours before the procedure
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In patients with impaired CrCl (<50 mL/min), dabigatran therapy should be stopped at least 72 hours before the procedure if CrCl is 30 to less than 50 mL/min and at least 4 days earlier if CrCl is less than 30 mL/min. Rivaroxaban and apixaban administration should be stopped at least 48 hours before the procedure.
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High bleeding risk procedures( including major cardiac surgery, insertion of pacemakers or defibrillators, neurosurgery, major cancer/urologic/vascular surgery, spinal puncture, etc.) In patients with normal CrCl (50 mL/min), dabigatran, rivaroxaban, and apixaban administration should be stopped at least 48 hours before procedure.
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In patients with impaired CrCl (<50 mL/min), dabigatran use should be stopped at least 4 days before the procedure if CrCl is 30 to less than 50 mL/min and at least 6 days earlier if CrCl is less than 30 mL/min . Rivaroxaban and apixaban administration should be stopped at least 4 days before the procedure.
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REINITIATION This process depends on the nature of the surgery, the urgency for restarting thromboprophylaxis therapy, and the hemostatic state of the patient. Given the rapid clearance of the NOAs from the circulation and the rapid onset of action when reintroduced, no bridging therapy with LMWH or unfractionated heparin is necessary.
Slide 26-

Anticoagulation may be resumed the same evening, at least 4 to 6 hours after surgery with a reduced dose (dabigatran, 75 mg; rivaroxaban, 10 mg; or apixaban, 2.5 mg) for the first dose and, thereafter, the usual maintenance dose. For major abdominal surgery or urologic surgery with incomplete hemostasis, resumption should be delayed until there is adequate hemostasis
Slide 27-

There are no standardised tests readily available in routine practice for monitoring the anticoagulant effects of the NOACs. There are no specific antidotes for NOACs Administration of oral activated charcoal retards absorption of recently ingested drug, eg, within a couple of hours of intake.( Am J Hematol. 2012;87)
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Given that only 35% of dabigatran is bound to plasma proteins, hemodialysis typically removes 60% of dabigatran and should be considered, especially in patients with impaired renal function.
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Octaplex A randomized controlled study using a nonactivated 4-factor PCC showed normalization of the PT alone in patients taking rivaroxaban but not dabigatran.
Slide 30-

There is some evidence to support the use of activated prothrombin complex concentrates (aPCCs) [Feiba®] for reversal of dabigatran or four-factor PCC [Octaplex®] as reversal agents for rivaroxaban and apixaban but data is limited.