Perioperative Medicine (0-5%) Complete Flashcards
CCS 2016: Preop Cardiac Risk Evaluation
Timing of surgery with Stents (CCS 2018)
Elective surgery
• Delay _______ after POBA [AHA/ACC 2014, no guidance in CCS 2018]
• Delay at least _______ after BMS
• Delay at least _______ after DES
• If semi-urgent (ex. Malignancy, where feasible) delay at least _______ post-PCI
• Continue _______ wherever possible
• Hold clopidogrel / ticagrelor _______ days, prasugrel _______ days.
Elective surgery
• Delay 14 days after POBA [AHA/ACC 2014, no guidance in CCS 2018]
• Delay at least 1 month after BMS
• Delay at least 3 months after DES
• If semi-urgent (ex. Malignancy, where feasible) delay at least 1-month post-PCI
• Continue ASA wherever possible [CCS 2018 Antiplatelet Guideline, weak recommendation]
• Hold clopidogrel / ticagrelor 5-7 days, prasugrel 7-10 days.
ASA – CCS Guidelines 2016
• Physicians should discontinue ASA at least ________ days before noncardiac surgery to reduce the risk of major bleeding.
– UNLESS:
___________________________________
ASA – CCS Guidelines 2016
• Physicians should discontinue ASA at least 3 days before noncardiac surgery to reduce the risk of major bleeding.
– UNLESS: recent coronary stent or in pts undergoing carotid endarterectomy
– “Recent” = 6 weeks BMS, 3-12 months DES [depends on stent generation] “Ask their cardiologist*”
REAL WORLD: Continue ASA with history of coronary stent even >1 year “wherever possible (unless procedure very very high risk bleeding ex. neurosurgery)”… per CCS 2018 Antiplatelet Guidelines
ASA Mgmt with coronary stents: Bottom Line
Patient on ASA for a frivolous reason (eg 1o prevention)
- _____________________
Patient on ASA for secondary prevention (eg PAD, prior stroke/TIA, CAD without stents)
- _____________________
The patient has a stent of any duration:
- _____________________________________
- If the patient on clopidogrel maintenance:
_______________________________________
Patient on ASA for frivolous reason (eg 1o prevention)
- stop ASA 7 days preop
Patient on ASA for secondary prevention (eg PAD, prior stroke/TIA, CAD without stents)
- stop ASA 72 h preop
Patient has a stent of any duration:
- continue ASA if surgeon agrees
- If the patient on clopidogrel maintenance :
change to ASA 81mg perioperatively
ACEi/ARB peri-operatively?
• 2016 CCS guidelines?
• 2016 CCS guidelines:
– We recommend holding ACEI/ARB starting 24 hours before noncardiac surgery in patients treated chronically with an ACEI/ARB.
“Restart day 2 after surgery if the patient is hemodynamically stable”
Practical Tip:
Do not automatically reorder POD #2. Reassess when to restart postop based upon volume status, BP, Creatinine
POISE3 and Tranexamic acid?
– TXA 1g at the start and end of surgery vs placebo
• OUTCOME: Composite of life threatening, major bleeding and bleeding into the critical organ at 30d
= **Significant reduction of bleeding* (9.1% vs 11.7%, HR 0.76, p<0.001) [Deveraux PJ et al, NEJM 2022]
DMARDs and Biologics in perioperative?
– Nonbiologic disease-modifying antirheumatic drugs may be continued throughout the perioperative period.
– Severe (organ-threatening) SLE biologics continue w a consult of rheum.
– Biologic medications should generally be withheld as close to 1 dosing cycle as scheduling permits prior to elective THA/TKA & restarted after evidence of wound healing. (eg) infliximab dosed q4 weeks: skip the dose, surgery week 5
– Restart medication once the wound shows evidence of healing, once staples/sutures are out, typically ~ 14d.
Perioperative anticoagulation:
Procedural Risk: Low Bleeding Risk, anticoagulation can be continued?
• Minor dental procedure:
– Up to 2 teeth removal; root canal; periodontal surgery; teeth cleaning
– Continue VKA and use oral prohemostatic agent
• Minor derm procedure: skin biopsy
• Cataracts
• Minor procedures with small bore needles (ex paracentesis, thoracentesis)
• Endoscopic procedures not requiring biopsy: sigmoidoscopy for Crohn’s
Perioperative anticoagulation:
Procedural risk: High bleeding risk,
must HOLD anticoagulants?
• Any procedure involving neuraxial anesthesia
• Neurosurgery (intracranial or spinal surgery)
• Cardiac surgery (e.g. CABG, heart valve replacement)
• Major vascular surgery (e.g. aortic aneurysm repair, aortofemoral bypass)
• Major urological surgery (e.g. prostatectomy, bladder tumor resection)
• Major lower limb orthopedic surgery (e.g. hip/knee joint replacement surgery)
• Lung resection surgery
• Intestinal anastomosis surgery
• Selected procedures (e.g. kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy)
Perioperative anticoagulation:
Which of these patients should* be bridged? (Only for _______)
- __________________
- __________________
- __________________
- __________________
- __________________
- __________________
Which of these patients should* be bridged? (Only for Warfarin)
– Mechanical MVR or older AVR (ballcage, tilting)
– DVT, PE or Arterial TE <3 mos
– Chronic AFIB, CHADS 5-6
– Rheumatic mitral stenosis
– Prior thrombosis when warfarin held
– Severe thrombophilia (APLA, Protein C, S, ATIII deficiency)
Example of How to Bridge – Warfarin and LMWH (assumes normal CrCl)
Perioperative anticoagulation:
Pre-Op management of DOACs
When to give the last dose before OR?
Post-OP management of DOACs
Peri-op Management of New Antiplatelets
Neuraxial anesthesia and anticoagulation
Time AFTER puncture /catheter manipulation or removal and when to start VTE prophylaxis
Postop VTE Prophylaxis (PPx) – ASH 2019
Recommendation against using pharmacologic ppx:
______________________
______________________
______________________
______________________
Postop VTE Prophylaxis (Ortho) – ASH 2019, Thrombosis Canada
Postop VTE Prophylaxis Regimens
Non-Pharmacologic: Choose _________?
Pharmacologic heparin dosing: _______
Non-Pharmacologic: • Intermittent pneumatic compression (IPC favored over stockings in guidelines)
Pharmacologic
• LDUH 5000 u sc BID or TID
• LMWH
• Enoxaparin 30 mg sc BID or 40 mg sc OD
• Dalteparin 5000 u sc OD
• Tinzaparin 4500 u scOD or 75u/kg scOD
• Nadroparin 38u/kg day 1-3 then 57u/kg
>POD 4
Diabetes Management Peri-Op:
SGLT2 inhibitor*: Hold ______ days before OR [FDA – _____ days for ertugliflozin]
Why hold?
SGLT2 inhibitor*: Hold 3 days before OR [FDA – 4 days for ertugliflozin]
Why hold? Euglycemic DKA
Anemia and Blood Product Management
• Preop optimization of Hgb if anemic (women: <_____, men: <_____)
– Consider pre-operative _________
– Target Hgb before major joint arthroplasty = _______
• __________ reduces perioperative blood loss, # of patients requiring transfusion, and # of units transfused and Is routinely given by anesthesia intra-op for high-risk bleeding procedures (ortho)
Anemia and Blood Product Management
• Preop optimization of Hgb if anemic (women: <115, men: <130)
– Consider pre-operative iron (oral or IV) and erythropoietin pre-operatively
– Target Hgb before major joint arthroplasty = 130
• Tranexamic acid reduces perioperative blood loss, # of patients requiring transfusion, and # of units transfused. and is routinely given by anesthesia intra-op for high-risk bleeding procedures (ortho)
