Module 8

Question 1

What are the circumstances when surgery should be deferred in the setting of anticoagulation?

Answer 1

• ischaemic stroke in last month
• arterial thrombosis in last month
• proximal DVT/PE in last 3 months
• AF + high thrombotic risk without anticoagulation in last month

Question 2

When is anticoagulation able to be maintained throughout perioperative period?

Answer 2

• superficial/cutaneous dermatological surgery
• simple tooth extractions
• cataract surgery
• PPM insertion
• endovascular procedures

Question 3

Which cardiac valves DONT need bridging?

Answer 3

Modern bileaflet aortic valves

Question 4

How long is it advised to delay surgery after insertion of BMS or DES?

Answer 4

BMS 6 weeks
DES 12 months

(recent evidence to suggest no difference after 6 months)

Question 5

How far pre-op should the following agents be held?

• ticagrelor
• clopidogrel
• prasugrel

How would you bridge them if you needed to?

Answer 5

ticagrelor 3-5 days
clopidogrel 5 days
prasugrel 7 days

can use tirofiban infusion, don’t use heparin/LMWH

Question 6

What are some management strategies for operative bleeding in a patient on antiplatelet agents?

Answer 6

Platelet transfusion
Fibrinogen/cryo to increase clot stability
TXA to ensure clot longevity
Desmopressin if uraemic

Question 7

What are some presenting symptoms and signs of epidural haematomas?

Answer 7

sudden, severe, constant back pain
worsens on percussion and with straining
progressive motor/sensory block
bowel or bladder dysfunction

Question 8

What are the appropriate imaging and management strategies for epidural haematomas?

Answer 8

MRI (CT if MRI not available

Reverse anticoagulation if possible
Platelet transfusion if on anti-platelets

Decompressive lami within 8 hours

Question 9

When should you restart aspirin after CABG?

When would you consider adding other agents? Which agents?

Answer 9

6 hours post

Consider adding prasugrel or ticagrelor if recent ACS