Problem 6: Anticoagulant bridging for operation procedure Flashcards
Explain why warfarin has been omitted
Stop warfarin 5 days before planned surgery so that INR is reduced and bleeding risks are reduced for when the patient has surgery. Over anti-coagulation could be fatal in surgery. Warfarin omitted preferably but can be actively reversed if necessary.
Explain why the doctor has advised for vitamin K to be given. How much should be administered?
Vitamin K is given to reverse the anti-coagulation of warfarin. Konakion MM is indicated as an antidote to anticoagulant drugs of the coumarin type in the treatment of haemorrhage or threatened haemorrhage, associated with a low blood level of prothrombin or factor VII.
Patients who require emergency surgery that can be delayed for 6-12 hours can be given 5 mg intravenous vitamin K1 to reverse the anticoagulant effect. Konakion MM Ampoules are for intravenous injection and should be diluted with 55ml of 5% glucose before slowly infusing the product. The solution should be freshly prepared and protected from light
Does the patient require a LMWH like enoxaparin before surgery, or will this increase the bleeding risk? Explain the advantages and disadvantages of LMWH vs unfractionated heparin?
Patients on long term warfarin, and are at high risk of VTE may have their warfarin substituted for LMWHs before surgery - this is known as bridging.
VTE prophylaxis: mechanical VTE prophylaxis includes anti-embolism stockings, foot impulsive devices and intermittent pneumatic compression devices.
Pharmacological VTE choice of medication is based on local policies and individual patient factors, including clinical conditions.
General medical patients: LMWH, fondaparinux sodium or unfractionated heparin.
Patients with stroke - LMWH
(or UFH in renal failure)
CEntral venous catheters - LMWH (or UFH in renal failure)
Elective hip replacement
Provided there are no contraindications, start pharmacological VTE prophylaxis after surgery. Choose any one of:
dabigatran etexilate, starting 1–4 hours after surgery[7]
fondaparinux sodium, starting 6 hours after surgical closure provided haemostasis has been established
LMWH, starting 6–12 hours after surgery
rivaroxaban, starting 6–10 hours after surgery[8]
UFH (for patients with severe renal impairment or established renal failure), starting 6–12 hours after surgery.
Anna is on warfarin for AF - does this mean that the warfarin can be safely omitted?
For patients with AF, the CHADVASc score is used to predict stroke risk, previous guidelines have outlined that bridging is needed for those most at risk or with previous stroke or TIA. Patients with previous stroke or TIA in last 3 months should have heparin bridging considered. As should patients with >140/90mmHg on medication or congestive heart failure or over 75s or diabetes.
