Pré-op Flashcards
RCRI
- MCAS
- IC
- ACT-ICT
- Utilisation d’insulines pour DB
- Créatinine sérique >177
- Chirurgie haut risque (Intrathoracique, intrapéritonéal ou vasculaire suprainguinale)
MI, ACR ou décès à 30j
0: 4%
1: 6%
2: 10%
3+: 15%
Warfarine in AFib - When to stop for surgery
D/C 5d before. INR at day -1.
Low bleeding: ok if INR < 1.5
Moderate-high risk: ok if INR <1.2
LMWH J-3, J-2, J-1 si low risk bleeding
Indications for bridging in VKA - Periop
-Mechanical valve
-Moderate to severe mitral valve stenosis
-CHADS 5-6
-Recent stroke/TIA
HBPM 3d before surgery. 50% dose the day before surgery (or only AM if BID regimen)
OAC in emergency procedure - Reversal
VKA:
-vitamine K 5-10 mg IV
-consider PCC (prothrombin complex concentrate) or aPCC
DOAC:
-Antidote (idarucizumab ou andexanet alfa)
-consider PCC or aPCC
DOAC antidote
Idarucizumab: dabigatran
Andexanet alfa: apixaban, edoxaban et rivaroxaban (dose reçue il y a <18h)
**Avoid if anticipated to require UFH or LMWH within 12-24h.
OAC in urgent procedure - Reversal
Differ surgery 12-24h if possible
-VKA: vit. K 2.5-5 mg IV
-DOAC: antidote if needed
Anti-Xa low-moderate bleeding risk - Calendar
Stop at day -1
Start at +1
Anti-Xa high bleeding risk - Calendar
Stop at day -2 (last dose j-3)
Start at j+2
Dabigatran <50 ml/min - Low-moderate bleeding
Stop at day -2 (last doses at j-3)
Start at +1
Dabigatran <50 ml/min - High bleeding - Calendar
Stop at day -4 (last dose j-5)
Start at day +2
OAC post-op - When to start
Low risk bleeding: 24h
High risk bleeding: 48-72h
Cardiac surgery: consider withholding for 72h
Drugs used for Bridging + doses
Enoxaparin 1 mg/kg BID
Enoxaparin 1.5 mg/kg die
Dalteparin 100U/kg BID
Dalteparin 200U/kg die
Tinzaparin 175U/kg die
Significant bleeding - Activate charcoal
If DOAC ingestion <4h
Life-threatening bleeding - Treatment
DOAC: aPCC/PCC, andexanet alfa ou idarucizumab
VKA: aPCC/PCC, vit. K 5-10 mg, FFP*
Consider acid tranexamique ou aminocaproique
Do not administer hemostatic agent if antidote has been given
Life-threatening bleeding - Examples
Intracranial
GI with HD instability
Muscular with compartment syndrome
Retroperitoneal
VINDICATE
V: Vascular
I: Infectious and inflammatory
N: Neoplastic
D: Degenerative, deficiency, and drugs
I: Idiopathic, intoxication, and iatrogenic
C: Congenital
A: Autoimmune, allergic, and anatomic
T: Traumatic
E: Endocrine
FR BAV post-op
BBD pré-op (surtout tricuspide)
BBG préop
BAV 1er préop
ATCD chirurgie valvulaire
Réopération
Âge >70 ans
Temps clampage prolongé
Absence de rythme sinusal en pré-op
TAVI: corevalve (Self expandable)
Maze donne surtout atteinte NS
Transplant: Moins de pacemaker avec anastomose bi-cavale au lieu de bi-atrial.
FR BAV post-TAVI
ECG: BBD > BBG > BAV 1er > HBAG
Prothèse: pré-dilatation et post-dilatation, self expandable (Corevalve), oversizing ou encore ratio prothèse/LVOT augmenté >1, implantation profonde (bas implanté), calcification dans le landing zone
Diamètre télédiastolique VG augmenté
Chirurgie à faible risque CV
Cataracte
Sein
Endoscopique
Chx superficielle
Chx d’un jour
Chx haut risque CV
Vasculaire suprainguinale
Thoracique
Abdominale rétropéritonéale
Indications de demander BNP pré-op
RCRI >/= 1
>65 ans
45-64 ans et ATCD CV majeur
NT-BNP >/= 300: tropo 48-72h et ECG post op
Bleeding risk of surgical procedures
