Hematology and Oncology Book

Cancer

Coagulopathy

  • Perioperative Anticoagulation

http://www.fpnotebook.com/

Perioperative AnticoagulationAka: Anticoagulation in Surgical Patients, Surgical Patients on Anticoagulation, Coumadin Protocol for the Perioperative Period, Warfarin Protocol for the Perioperative Period, Bridge Therapy Protocol, Bridging Therapy

Advertisement

  1. See Also
    1. Coumadin
    2. Coumadin Protocol
    3. Coumadin Drug Interactions
    4. Deep Vein Thrombosis Prevention
  2. Indications
    1. Patients on Anticoagulation undergoing surgery
  3. Pitfalls
    1. Over Anticoagulation or premature use results in significantly increased bleeding complications
    2. Bleeding complications result in transfusions and stopping Anticoagulation which risks clots
  4. Protocol: Simplified Bridging Protocol
    1. Day -7: Stop Aspirin, Obtain INR
    2. Day -5: Stop Warfarin, Check INR
    3. Day -3: Start Low Molecular Weight Heparin at full dose given every 12-24 hours
    4. Day -1:
      1. Stop or give half dose LMWH 12-24 hours before procedure
      2. Administer Vitamin K 1 mg PO if INR >1.5
    5. Day 0: Surgery
      1. No LMWH
      2. Restart Warfarin on evening of surgery
    6. Day 1:
      1. Continue Warfarin
      2. Consider restarting LMWH per therapeutic or prophylactic dosing
        1. See below for how to choice dosing regimen
    7. Day 2-10: Obtain INR and stop LMWH when INR >2
      1. Use caution in postoperative Anticoagulation (risk of bleeding events)
  5. Protocol: Invasive procedures with moderate bleeding risk
    1. Indications: Procedures with high bleeding risk
      1. Neurosurgery
      2. Abdominal or pelvic procedures
      3. Orthopedic joint procedures
      4. Major ENT or oral surgery
      5. Endoscopy with biopsy
      6. Epidural Anesthesia
      7. Prolonged general anesthesia with intubation
    2. Low risk for thromboembolism
      1. Indications
        1. No DVT for 3 months
        2. Chronic Atrial Fibrillation without stroke
        3. New bileaflet aortic valves
      2. Management
        1. Stop Warfarin 4 days before surgery
        2. Allow INR to normalize
        3. Post-operative DVT Prophylaxis if indicated
        4. Restart Warfarin postoperatively
    3. Intermediate risk for thromboembolism
      1. Indications
        1. Atrial Fibrillation with CHADS-2 Score 4 or higher
      2. Management
        1. Stop Warfarin 4 days before surgery
        2. Allow INR to decrease
        3. Start Anticoagulation 2 days before surgery
          1. Low dose Heparin 5000 U SC or
          2. Low Molecular Weight Heparin at prophylactic doses
        4. Restart low dose Heparin or LMWH postoperatively (hold for 24-48 hours postoperatively)
        5. Restart Warfarin immediately postoperatively
    4. High risk for thromboembolism
      1. Indications
        1. Deep Vein Thrombosis within last 3 months
        2. Pulmonary Embolism within last 3 months
        3. Cardiac thromboembolism (any cause) within 1 month
        4. Recurrent Venous Thromboembolism
        5. Strong Thrombophilia
          1. Active cancer
          2. Antiphospholipid Antibody Syndrome (uncommon)
          3. Antithrombin III deficiency (rare)
          4. Protein C Deficiency
          5. Protein S Deficiency
        6. Mechanical heart valves
          1. Mitral valve replacement
          2. Ball-Cage or other older cardiac valve
          3. Higher risks
            1. Comorbidity (e.g. Congestive Heart Failure)
            2. Atrial Fibrillation with mechanical valve
          4. Exceptions: Lower risks (not needing bridging)
            1. New aortic valves (see above)
      2. Management
        1. Stop Warfarin 4 days before surgery
        2. Allow INR to decrease
        3. Start Anticoagulation 2 days before surgery
          1. Full dose Heparin or
          2. Full dose Low Molecular Weight Heparin
        4. Hold Heparin before surgery
          1. Hold Heparin IV for 5 hours before surgery
          2. Hold LMWH for 12-24 hours before surgery
        5. Restart Heparin after procedure
        6. Restart Warfarin postoperatively
  6. Protocol: Procedures with low risk of bleeding
    1. Low risk of bleeding: Orthopedic or Gynecologic Surgery
      1. Lower Warfarin dose 4 to 5 days before surgery
      2. Target INR of 1.3 to 1.5 before surgery
      3. Restart Warfarin at regular dosing after surgery
      4. Consider adjunctive Heparin at 5000 U SC post-op
    2. Very low risk of bleeding
      1. Procedures
        1. Dental procedures
        2. Cataract Surgery
        3. Dermatologic procedures
        4. Pacemaker and IACD placement
        5. Endoscopy without biopsy
      2. Protocol
        1. Continue Warfarin at current dose
        2. Keep INR < 3.0
        3. Only discontinue Warfarin for high bleeding risk
        4. Consider local bleeding control if needed (dental)
          1. Tranexamic acid
          2. Epsilon amino caproic acid mouthwash
  7. Protocol: Normalization of INR after stopping Coumadin
    1. Anticipate INR normalization after stopping for 4 days
      1. Bleeding risk is low when INR <1.5
    2. Indications for transiently stopping Coumadin
      1. Prolonged INR
      2. Surgery
    3. Factors predicting delayed INR decrease
      1. Advanced age (80 years or older)
      2. Coumadin sensitive (maintenance dose <15 mg/week)
      3. Decompensated Congestive Heart Failure
      4. Active malignancy
      5. Liver disease
      6. Concurrent medications that potentiate Coumadin
        1. See Coumadin Drug Interactions
    4. Options for reversal
      1. Vitamin K (preferred if >12 hours pre-operative)
        1. Time to surgery >24 hours
          1. Vitamin K 1.0-2.5 mg PO one dose
          2. Maximum Vitamin K dose: 5 mg (risk of resistance)
        2. Time to surgery 12-24 hours
          1. Vitamin K 0.5 mg IV slow infusion one dose
      2. Clotting Factor replacement (within 12 hours)
        1. Fresh Frozen Plasma (FFP) 15 ml/kg
    5. Example Protocol
      1. PM prior to surgery: Vitamin K 1-2.5 mg PO x1 dose
      2. AM of surgery: FFP if INR >1.5
      3. Post-operatively (12-24 hours): Anticoagulate
        1. See protocols above for agents and dosing
  8. Protocol: Antiplatelet agents
    1. Plavix, Aspirin poison platelets for full 21 day life
    2. Agents stopped 7 days before surgery
      1. Allows 33% of platelets to regenerate (50,000)
  9. References
    1. Ansell (2001) Chest 119(1 Suppl):22S
    2. Hylek (2001) Ann Intern Med 135:393

Navigation Tree