Exxcellence pearls: Perioperative management anticoagulation Flashcards
What bridging therapy is recommended for patients with high-risk of thromboembolism?
Therapeutic subcutaneous low molecular weight heparin or therapeutic IV unfractionated heparin.
Describe the risk stratification system for venous thromboembolism.
High-risk: recent stroke, mitral valve prosthesis, older aortic valve prosthesis, severe thrombophilia, atrial fibrillation with CHADS2 score of 5-6, DTE within 3 months.
Moderate risk: bileaflet aortic valve prosthesis with complicating factors, atrial fibrillation with CHADS2 score 3-4, nonsevere thrombophilia such as factor five Leiden heterozygotes, active cancer, VTE within 3-12 months.
Low risk: bileaflet aortic valve prosthesis with no complicating factors, atrial fibrillation with CHADS2 score of 0-2, single VTE greater than 12 months ago with no ongoing risk factors.
What types of gynecologic surgery are thought to have the highest risk of bleeding?
Cancer and bladder surgeries.
What bridging therapy is recommended for those at moderate risk?
Therapeutic or prophylactic subcutaneous low molecular weight heparin or therapeutic IV unfractionated heparin is acceptable.
When should bridging therapy be restarted after minor procedures?
After major procedures?
24 hours.
48-72 hours
When should therapeutic low molecular weight heparin he stopped prior to procedures?
When should prophylactic dose low molecular weight heparin be stopped?
24 hours.
12 hours.
When should IV unfractionated heparin be stopped prior to procedures?
4 hours.
What is the mechanism of action of warfarin?
When should this be stopped prior to surgery?
Vitamin K antagonist.
Five days prior to the procedure.
How can warfarin be reversed for urgent surgery?
What can be added to expedite reversal in the setting of emergency surgery?
IV or oral vitamin K.
Fresh frozen plasma.
When should clopidogrel be discontinued prior to surgery?
5-10 days.
When should aspirin be discontinued for low-risk patients prior to surgery?
7 days. For high-risk CAD patients aspirin should be continued.
How can patients undergoing urgent or emergent surgery with recent antiplatelet medication use be managed?
Prohemostatic agents and platelet transfusion
What should be recommended for women with drug-eluding stents who require surgery?
Within the first 12 months, continuation of aspirin and clopidogrel is recommended.
How long should women wait to undergo elective procedures after cardiac revascularization with bare metal stents?
If surgery is required what can be done to reduce the risk of thrombotic events?
At least 2 weeks, preferably 6 weeks.
Antiplatelet medications should be continued.
