Peri-operative Anticoagulation Management

Question 1

In which procedures can anticoagulation be continued?

Answer 1

(1) Minor dental procedures (up to 2 teeth removed, root canal, periodontal surgery, teeth cleaning)
(2) Minor Derm Procedures (Skin Biopsy)
(3) Cataracts
(4) Endoscopy Procedures NOT requiring biopsy.

Question 2

How would you manage a patient on anticoagulation prior to EMERGENT surgery?

Answer 2

(A) VKA - Give Vitamin K 5-10 mg and consider PCC or aPCC 30-50 IU/kg

(B) DOAC - Consider antidote OR consider PCC or aPCC 50 IU/kg if no antidote available.

Question 3

How would you manage anticoagulation in a patient requiring an urgent procedure?

Answer 3

(A) VKA - Defer surgery 12-24 hrs (if possible) & give vitamin K 2.5-5 mg.

(B) DOAC - Defer surgery 12-24 hrs (if possible)

Question 4

Which patients with previous VTE require bridging in the peri-operative period?

Answer 4

(1) VTE w/in 3 months

2) High Risk Thrombophilia (APLA, Protein C or Protein S deficiency, Factor III (Antithrombin) Deficiency

Question 5

In which patients with atrial fibrillation would you bridge anticoagulation in the post-operative period?

Answer 5

Atrial fibrillation AND:

(1) CHADS 5 or 6
(2) Rheumatic Valve
(3) Mechanical Valve
(4) Previous stroke within last 3 months

Question 6

In which scenarios to do mechanical valves require peri-operative anticoagulation bridging?

Answer 6

(1) Mechanical Mitral Valve
(2) Old Mechanical AVR (Ball-cage, titling disc)
(3) Any mechanical valve w/atrial fibrillation, LV dysfunction, hypercoagulable state.
(4) Mechanical valve with stroke in the last 6 months.

Question 7

If a patient’s eGFR is > 30, how long should you hold DOAC prior to surgery?

Answer 7

Rivaroxaban/Apixaban/Edoxaban:

Standard Bleeding Risk - Last dose 2 days before surgery.
High Risk of Bleeding - Last dose 3 days before surgery.

Question 8

If a patient’s eGFR is < 30, how long do you would DOAC before surgery?

Answer 8

Riva/Edox/Apixaban

Standard Bleeding Risk - Last dose 3 days before OR
Increased Bleeding Risk - Last dose 4 days before OR

Question 9

How do you manage dabigatran pre-operatively?

Answer 9

CrCl > 50
Standard Bleeding Risk - Last dose 2 d before OR
High Bleeding Risk - Last dose 3 d before OR

CrCl 30-49
Standard Bleeding Risk - Last dose 3 d before
High Bleeding Risk - Last dose 5 d before

Question 10

When can you re-start IV heparin or SC heparin prophylaxis after neuraxial anasthesia?

Answer 10

IV Heparin - 1 hr after puncture/catheter removal.

SC heparin - Same

Question 11

When can you re-start LMWH after neuraxial anasthesia?

Answer 11

4 hours

Question 12

When can you restart DOACS after neuraxial anasthesia?

Answer 12

4-6 hours later (dabigatran definitely 6)

Question 13

When can you re-start clopidogrel or ticagrelor after neuraxial anasthesia?

Answer 13

6 hours after

Question 14

When does therapeutic and prophylactic LMWH need to be stopped prior to surgery involving neuraxial anasthesia?

Answer 14

Prophylactic - 12 hours

Full Dose - 24 hours

Question 15

What is the maximum INR for neuraxial anasthesia?

Answer 15

< 1.4

Question 16

In which surgical situations would you NOT use prophylactic anticoagulation for post-op DVTp?

Answer 16

Per ASH Guidelines:

(1) Urologic Procedures
(2) High Risk Trauma
(3) Laproscopic Cholecystectomy
(4) Neurosurgical Procedures
(5) Knee arthroscopy or lower leg below knee surgery.

Question 17

What are the specific post-op VTE prophylaxis recommendations for THA or TKA?

Answer 17

ASA or DOAC for 14-35 days (extended course recommended)

DOAC options:

(1) Apixaban 2.5 mg PO BID
(2) Dabigatran 220 mg PO OD
(3) Rivaroxaban 10 mg PO OD

Question 18

What are the specific ASH guideline recommendations for VTEp post-op hip fracture surgery?

Answer 18

LMWH x 14-35 d (longer duration recommended)

Question 19

What are the LMWH options for VTEp?

Answer 19

(1) Enoxaparin 30 mg SC BID OR 40 mg SC OD
(2) Dalteparin 5000 U SC OD
(3) Tinzaparin 4500 U SC OD OR 75 U/kg SC OD