Blood thinners

Question 1

When should warfarin be stopped before surgery?

Answer 1

At least 5 days before surgery with a target INR of 1.5

Question 2

When should warfarin be reinstituted following surgery?

Answer 2

Warfarin should be reset 12-24 hours post op

Question 3

When is bridging therapy reccomended for patients undergoing surgical correction.

Answer 3

In high risk patients who have

• A-fib
• history of VTE
• Mechanical heart valve.

Commonly use enoxaparin (lovenox,Sanofi) or others.

Question 4

What is the reccomendation for patients on blood thinners undergoing minor dermatoligcal procedures?

Answer 4

these patients should only discontinue warfarin periperatively.

Surgeon should try to optimize local hemostasis and use Aspirin therapy.

Question 5

How must a surgeon face a patient that requires surgery but recently had a stent placed?

Answer 5

One should wait at least six weeks for a non drug eluting stent and 6 months for a drug eluting stent following the stent replacement barring it is not an emergent procedure.

Question 6

How long should bridging therapy be utilized for high risk patients during surgery?

Answer 6

At least 12 days post surgery until the patient’s INR returns to normal.

Question 7

How should you treat a patient who is currently on heparin bridging therapy but requires surgery?

Answer 7

Discontinue the heparin at least 4-6 hours before the procedure.
The last preoperative dose should be given 24 hours before surgery.

Question 8

How long must antiplatelet medications be abstained for platelet counts to achieve normal levels again?

Answer 8

It takes up to 10 days to replenish the platelet pool.

Question 9

When should one order an INR when considering surgery on a patient normally on blood thinners?

Answer 9

At least 24 hours before the surgery.

If still therapeutic may need to bring down with vitamin K or discontinue the surgery.

Question 10

What podiatric injury places the patient at greatest risk of VTE?

Answer 10

Achilles tendon rupture

Incidence of 7%

Question 11

What are some general risk factors for VTE?

Answer 11

Age > 60
Smoking
Malignancy
Obesity 
Major injury
Female
Birth control use
Immobilization

Question 12

What is the incidence of VTE without prophylaxis clinically vs radioraphically?

Answer 12

Clinically .6%

Radiography: 12.2%

Question 13

Name the three most common diagnostic imaging for DVT?

Answer 13

• Duplex ultrasonography
• Venography/Angiogram (more arterial)
• Impedance plethesmography

Question 14

What is the Law of 8018?

Answer 14

The ammount of unfractionated heparin used to treat DVT

80 mg/kg IV heparin bolus
18 mg/kg/hour.

Check the PTT every 6 hours until its 1.5-2.5 times normal (46-70s)

Question 15

What is the normal PTT?

Answer 15

46-70 seconds

Question 16

What is Enoxaparin?

Answer 16

Lovenox AKA Low molecular weight heparin

Question 17

Dose for Enoxaparin?

Answer 17

Lovenox/Low molecular weight heparin!

1mg/kg q12 injected subq

Question 18

What is the dose for warfarin?

Answer 18

Also known as coumadin!!
10 mg or 7.5 mg PO q daily for 2 days
Then adjust for normal INR 2.5-3

Question 19

What is rivaroxaban?

Answer 19

Xaralto

Question 20

What is Epixiban?

Answer 20

Elequis

Question 21

What is the dose for rivaroxaban for DVT/PE?

Answer 21

The dose for elequis is:
15 mg BID for 21 days
20 mg qD for 6 months

If continual following 6 months 10 mg/day

Question 22

What is the dose for apixiban for DVT/PE?

Answer 22

Apixiban is also known as Elequis

Dose: 10 mg BID for 7 days
5 mg BID for 7 days

Question 23

What is the immediate treatment choice for a life threatening pulmonary embolism?

Answer 23

Clot Busters!!!
Streptokinase 1.5 million units IV over 60 minutes
Urokinase 4400 units/kg IV over 10 minutes then 4400 units/kg/hr for 12 hours

Question 24

What is the classic triad of pulmonary embolism?

Answer 24

Shortness of breath
Chest pain
Hemoptysis

<14% of patients experience this though.