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Surgical Specialties > Anticoagulation Peri Op > Flashcards

Anticoagulation Peri Op Flashcards

1
Q

When to stop warfarin pre op if needs to be discontinued?

A

5 days pre op

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2
Q

Post op what should you give pts on warfarin with a VTE > 3months earlier?

A

Low dose LMWH

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3
Q

Which patients on warfarin should you consider bridging? Name 3 groups

A

Pts at v high recurrent VTE risk e.g VTE while on therapeutic dose anticoagulants or with a target INR 3.5 or have had a VTE in <3months

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4
Q

Do warfarinised patients with AF and a CHADS2 score < 4 and no stroke or TIA in last 3 months need bridging peri-operatively?

A

No

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5
Q

Pts with a bileaflet aortic mechanical heart valve that are warfarinsed peri -op should …
But…

A

Not require bridging

But can be considered in all other MHV patients

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6
Q

If indicated, When to stop clopidogrel and when prasugrel?

A

5 days, 7 days pre op respectively

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7
Q

When to stop ticagrelor if indicated?

A

5 days pre-op

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8
Q

What is used to bridge warfarin peri-operatively?

A

LMWH or UH

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9
Q

When can you resume warfarin post op?

A

12-24hrs if bleeding risk is low

48-72hrs post op if high bleeding risk

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10
Q

Dabigatran is 80% Renally excreted so interruption varies on creatinine clearance and bleeding risk of operation:.. Fill the hold times
Cr >80ml/min: x hrs low risk, x hrs high risk
Cr 50-79ml/min x low risk, x high risk
Cr 30-49ml/min x low risk, x high risk

A

Cr >80: 24hrs (48hrs high risk)
Cr 50-79: 36hrs (72hrs high)
Cr 30-49: 48hrs (96hrs high)

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11
Q

Apixaban, rivaroxaban, edoxaban interruption holding times:
Cr >30ml/min: x hrs low risk (x high risk)
Cr 15-29ml/min: x hrs low risk (high risk)

A

> 30: 24hrs (48hrs high risk)

15-29: 36hrs (48hrs high risk)

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12
Q

Resumption of DOAC therapy post op for low bleeding risk and high bleeding risk?

A

Low: 6-12hrs post op
High: 48-72hrs post op

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13
Q

What agent reverses dabigatran for an emergency high bleeding risk op?

A

Idarucizumab

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14
Q

What agent reverses Apixaban/Rivaroxaban/Edoxaban?

A

Andexanet

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15
Q

Pts with normal renal function for a low bleeding risk op, should not take DOAC x hrs pre-op

A

24hrs

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16
Q

Pts with normal renal function and a high bleeding risk op should not take DOAC x hrs pre-op

A

48hrs

17
Q

In terms of DOAC circulating concentration, what measurement can be used to confirm minimal conc vs what measurements can not .

A

✅Normal thrombin time = minimal conc

❌Normal PT/APPT not reliable

18
Q

If aspirin mono therapy is used for 2* prevention of CVD, should it be continued for non-cardiac invasive operations?

A

Yes can be continued

19
Q

If bleeding risk for an operation is high, and a pt is on aspirin when should it be omitted?

A

From day -3 to day +7 post op

20
Q

If pts on anti-platelet what should be done in case of

a) urgent low bleeding risk surgery
b) urgent high bleeding risk surgery

A

a) n/a (don’t need platelet infused)

b) consider pre-op transexamic acid

21
Q

If a pt on anti-platelets is given trasexamic acid pre-op for a high bleeding risk surgery but despite this has excessive periop bleeding what can be considered?

A

2 pools of donor platelets infusion

22
Q

In pts with a recent acute coronary syndrome/C.A stent on dual anti platelet therapy, undergoing a low bleeding risk operation…you should

A

Proceed without interruption to the anti platelet therapy

23
Q

In pts with a recent acute coronary syndrome/C.A stent on dual anti platelet therapy, undergoing a high bleeding risk operation…you should, if possible

A

Postpone the operation (if poss)

24
Q

In pts with a recent acute coronary syndrome/C.A stent on dual anti platelet therapy, undergoing a high bleeding risk operation…that cannot be postponed you should…

A

Continue aspirin
Clopidogrel/ticagrelor should be interrupted from 5 days pre-op
Or prasugrel from 7 days pre-op

aspirin should be continued and clopidogrel or ticagrelor interrupted from 5 days pre-op or prasugrel from 7 days pre-op

25
Q

Transexamic acid stabilises clots preventing haemorrhage by inhibiting ___ formation and displaces ____ from the ____ surface so it is an anti-___

A

Plasmin
Plasminogen
Fibrin
Anti-fibrinolytic

26
Q

Warfarin is a vit K antagonist inhibiting formation of clotting factors:____ and takes (x-X) days to take action

A 
II
VII
IX
X 
Protein C and S
27
Q

Name clotting factors in following aspects of Warfarin actions on the:
-intrinsic pathway: blood stream factors__
-extrinsic pathway: vessel wall factors__
These activate common pathway involving factors__

A

Intrinsic: IX, XI, XII
Extrinsic: III (tissue factor), VII
Common: X and II (prothrombin)

28
Q

Prothrombin time measures the ___pathway so can be used to monitor warfarin

A

Extrinsic

29
Q

Dabigatran acts by directly inhibiting ___ so delays the final step of coagulation cascade (___pathway)

A

Inhibiting thrombin

Common pathway

30
Q

Apixaban, dabigatran, edoxaban and rivaroxaban are all ___ used in the prevention and treatment of ___ they are also indicated to prevent stroke and systemic embolism in pts non-valvular __ who have at least 1 risk factor such as:

A
  • DOACs
  • VTE
  • AF
  • e.g. previous stroke, symptomatic HF, DM or HT
31
Q

MOA of DOACs - what part of coagulation pathway ..?

Dabigatran (doesn’t have x in name), acts at a slightly different point, -where?

A
  • acts on the final common pathway
  • directly inhibits activated factor X so prevents conversion of prothrombin to thrombin
  • Dabigatran directly inhibits thrombin (so prevents fibrinogen conversion to fibrin)
  • hence they prevent clot formation
32
Q

3 SEs of DOACs

A
  • bleeding: epistaxis, GI and GU haemorrhage
  • anaemia
  • GI upset
  • diziness
  • elevated LFTs
33
Q

3 DOAC CIs:

A
  • ACTIVE SIGNIF BLEEDING
  • RFS FOR MAJOR BLEEDING
  • PREGNANCY
  • BREASTFEEDING
  • RIFAMPICIN OR PHENYTOIN CONCURRENT USE (increases anti-coagulation effect)
34
Q

Warfarin is used for VTE rx/prophylaxis after initial hepain rx and to prevent clots in pts with AF or prosthetic heart valves, what is it’s MOA?

A

-inhibits hepatic production of vit-K dependent coagulation factors (II, VII, IX, X protein C&S) by inhibiting vitamin K epoxide reductase

35
Q

What is the substance that is used to reverse Wafarin? Or dried ______ complex can be used

A

Phytomenadione (vitamin K1)

-or dried prothrombin complex

36
Q

How long is a single episode of VTE treated with Warfarin for?

A

-3-6 months

37
Q

Target INR range for a pt on Warfarin for AF or VTE rx?

A

2-3 target range

Surgical Specialties (6 decks)

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