Pre-op anti platelet management

Question 1

A 70 year old man is booked for an elective cystoscopy. He is taking clopidogrel and aspirin because of emergency insertion of a coronary stent two months earlier. Outline your pre-operative management.

Answer 1

Introductory
For this patients upcoming elective cystoscopy there are two main surgical risks to be considered;
- bleeding risk from DAPT
- Cardiac risk given underlying pathology

Goals

• establish the urgency of the cystoscopy by discussing with uro
• pre-op assessment of bleeding risk vs thrombotic risk, and cardiovascular fitness - ultimately assessing the patients fitness for theatres
• Consult with surgical team and cardio to discuss risks/benefits of ceasing DAPT

Question 2

Pre-op antiplatelets - History

Answer 2

History
- confirm indication, enquire re urinary symptoms (Esp haematuria), planned biopsies? Establish urgency of the procedure (now or can be postponed?)
o if MI, then this is a contraindication to proceeding with elective surgery (post-pone for 6-12 months)
- Cardiovascular symptoms: pain, dyspnoea, etc. Can utilise Revised Cardiac Risk Index
- Cardiac risk: pre-existing cardiac function
- Bleeding risk: medications, adherence, ?;liver disease

Question 3

Pre-op antiplatelets - Examination

Answer 3

Examination

• Vitals
• Cardioresp exam: evidence of heart failure
• Peripheral vascular examination
• Signs of coagulopathy (petechiae, ecchymoses, etc)

Question 4

Pre-op antiplatelets - Investigations

Answer 4

Investigations
Main focus is on cardiac workup
- ECG
- FBC, Coags, UEC, LFT, G+H/xmatch

Question 5

Pre-op antiplatelets - Management

Answer 5

Management
Management involves consideration, assessment, and discussion of the patients bleeding risk with risk of thrombosis and cardiac event, with consultation with both urology and cardiology

1 - Potentially delay, as recent MI is strong predictor of adverse outcome. aim to delay until DAPT no longer required (will depend on degree of intended invasiveness of procedure)
- may have to postpone surgery for 6-12 months

2 - Optimise pharmacotherapy if cystoscopy goes ahead;

• Keep DAPT OR;
• Cease clopidogrel alone, and can operate on just aspirin alone: may increase risk of stent thrombosis, but reduce risk of bleeding intra-operatively
• Consider bleeding risk of specific surgery

3 - May have another ACS event, alternative anaesthetic options should be considered
- although flexible cystoscopy is performed under local anaesthetic

Other considerations

• Consider need for platelet infusion if catastrophic bleeding were to occur/emergency.
• consider the type of stent: bare metal vs drug-eluting - can cease the DAPT earlier in bare-metal stents as have quicker epithelialisation.