Download - Perioperative Medicine Pearls
Perioperative Pearls l Alraies l May 17, 2010
Perioperative Pearls, What Is Necessary And What is Appropriate
M Chadi Alraies, MD FACPCleveland Clinic FoundationCleveland, Ohio, USA
Saturday, April 8, 2023
Perioperative Pearls l Alraies l May 17, 2010
Disclosure
• None
Perioperative Pearls l Alraies l May 17, 2010
Overview
•M
edical consultant role perioperative care
–N
uts and bolts of the preop assessm
ent
•P
reoperative risk stratification
–C
ardiopulmonary risk
–R
isk reducing interventions
•P
erioperative anticoagulation in patients on V
KA
or those w
ith coronary stents
Perioperative Pearls l Alraies l May 17, 2010
Scope of the problem •
33 million surgeries every
year
•C
ost > $450 billion
•~
1 million pts/yr sustain
medical com
plications
–50,000 suffer perioperative M
IAM
I accounts for 40% of
perioperative mortality.
•In the next tw
o decades 25%
increase in number of
surgeries and 50% increased
in surgery related cost.
Perioperative Pearls l Alraies l May 17, 2010
Pathophysiology •
Stress
–O
xygen demand/supply
imbalance
–F
luctuation in heart rate and blood pressure from
volume shift
and blood loss
–G
eneration of a prothrombotic
state
•H
istopathologic studies of fatal perioperative M
I
–P
laque rupture accounted for less than 55%
of the cases
–S
everity of the lesion didn’t predict the site of the infarction
–A
significant proportion of infarcts occurred distal to non-critical stenosis.
Perioperative Pearls l Alraies l May 17, 2010
Surgery is Like a Plane Flight
Patient
Surgeon is the Pilot
Anesthesia is the Co-
Pilot
Michota F, Jaffer A. Clev Clin J Med 2006
Perioperative Pearls l Alraies l May 17, 2010
Medical Consultant = Mechanic
•W
hat is th
e co
nditio
n o
f the
p
lan
e?
•Is th
e pla
ne in th
e best
cond
ition to fly?
•U
nd
er the b
est cond
ition
s, w
ha
t can the
plane
h
and
le?
•Is th
e long
-term
m
ainte
nan
ce pro
gram
a
deq
uate
?
Perioperative Pearls l Alraies l May 17, 2010
•P
recise medical
diagnoses
•E
valuate the extent of organ disease
•O
ptimize all m
edical conditions
•A
ssess and describe physiologic lim
itations
•E
nsure adequate post-operative follow
-up
Medical Consultant = Mechanic
Perioperative Pearls l Alraies l May 17, 2010
Medical Consultant Role
•S
hou
ld not tell th
e p
ilot o
r the
co-p
ilot w
hen
or h
ow
to fly
•D
o no
t CL
EA
R pa
tients
for surge
ry “op
timize
”
•S
hou
ld not m
ake
ane
sthe
tic re
com
me
nda
tion
s
Perioperative Pearls l Alraies l May 17, 2010
Preoperative Evaluation•
Focus on
the history
–C
omplete
RO
S,
functional class, m
edications
•E
xam does
not need to be com
prehensive
•Laboratory testing should be selective, not routine
Perioperative Pearls l Alraies l May 17, 2010
Perioperative Pearls l Alraies l May 17, 2010
Perioperative Cardiac Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Case 1
•A
75-yo p
rese
nts pre
op fo
r a
radical prostate
ctom
y for
prosta
te ca
nce
r. PM
Hx
include
s CA
D w
ith h/o 3
V-
CA
BG
ab
out 2
yea
rs ag
o, HT
N
and
Typ
e 2 D
M. H
is current
me
ds in
clude
: insu
lin, a
teno
lol,
AS
A. H
e is ve
ry active
swim
min
g several la
ps fo
r
abo
ut 3
0 m
inu
tes at lea
st 3
time
s per w
ee
k; no C
P b
ut he
doe
s ge
t SO
B.
•E
xam: P
=6
8, BP
=1
30
/75
,
RR
=1
8
•L
ung
s=C
TA; h
eart exa
m is
norm
al e
xcept fo
r a
para
do
xical sp
lit S2
; LE p
ulses
are n
orm
al.
Perioperative Pearls l Alraies l May 17, 2010
Question•
According to the current
AC
C/A
HA
guidelines, is an E
CG
recomm
ended for this patient?
A.
Ye
s
B.
No
Perioperative Pearls l Alraies l May 17, 2010
Question•
According to the current
AC
C/A
HA
guidelines, is an E
CG
recomm
ended for this patient?
A.
Ye
s
B.
No
EKG is normal sinus with left anterior hemiblock
Perioperative Pearls l Alraies l May 17, 2010
What is the most appropriate next step in regards to his cardiovascular risk?
A.
Ga
ted
trea
dm
ill e
xercise
test
B.
Exe
rcise th
alliu
m
scintig
rap
hy
C.
Do
bu
tam
ine
e
cho
card
iog
rap
hy
D.
Co
ron
ary a
ng
iog
rap
hy
E.
No
ad
ditio
na
l tests
Perioperative Pearls l Alraies l May 17, 2010
What is the most appropriate next step in regards to his cardiovascular risk?
A.
Ga
ted
trea
dm
ill e
xercise
test
B.
Exe
rcise th
alliu
m
scintig
rap
hy
C.
Do
bu
tam
ine
e
cho
card
iog
rap
hy
D.
Co
ron
ary a
ng
iog
rap
hy
E.
No
ad
ditio
na
l tests
Perioperative Pearls l Alraies l May 17, 2010
ACC/AHA GuidelinesP
reop
EC
G reco
mm
end
ed
•C
las
s I
–V
ascu
lar su
rge
ry patien
ts with
1
risk facto
r*
–K
now
n CA
D, P
VD
, CV
D g
oin
g
for inte
rmed
iate risk surg
ery
•C
las
s IIa
–V
ascu
lar su
rge
ry
•C
las
s IIb
–Inte
rme
dia
te risk surg
ery
with 1
risk facto
r*
Fleisher LA et al. JACC 2007
Ischemic heart diseaseHeart failure
DiabetesRenal impairment
Cerebrovascular disease
Perioperative Pearls l Alraies l May 17, 2010
J Am Coll Cardiol. 2007 Oct 23;50(17):1707-32.
Perioperative Pearls l Alraies l May 17, 2010 Perioperative Pearls l May 17, 2010 l
Fleisher LA et al. J Am Coll Cardiol. 2007 Oct 23;50(17):1707-32.
Perioperative Pearls l Alraies l May 17, 2010 Perioperative Pearls l May 17, 2010 l
Fleisher LA et al. J Am Coll Cardiol. 2007 Oct 23;50(17):1707-32.
Factors Leading to Cumulative Risk for Perioperative Cardiac Events
Perioperative Pearls l Alraies l May 17, 2010
Case 2•
65 year old postmenopausal
female w
ith medical history of
HT
N, C
AD
, atrial fibrillation and dyslipidem
ia presents to the em
ergency department
complaining of acute onset of
leg pain.
•F
urther testing and evaluation reveals that she has an acute arterial em
boli and needs im
mediate em
bolictomy.
• H
er heart rate is 85 bpm.
Perioperative Pearls l May 17, 2010 l
Perioperative Pearls l Alraies l May 17, 2010
As the medical consultant, what is the MOST APPROPRIATE next step?1.
Com
plete a full preoperative evaluation, including a stress test, because she w
ill need a vascular procedure.
2.A
sk the patient about her physical activity so you can calculate her m
etabolic equivalents because she w
ill have an interm
ediate-risk surgery.
3.E
valuate her postoperatively for signs and sym
ptoms of a
myocardial infarction (M
I).
4.A
sk for surgery to be delayed for 2 days until a β
blocker low
ers her heart rate to betw
een 55 and 65 bpm
slowly.
Perioperative Pearls l May 17, 2010 l
Perioperative Pearls l Alraies l May 17, 2010
Tailoring the Perioperative Evaluation Based on the Urgency of Surgery
Perioperative Pearls l May 17, 2010 l
Emergent surgery?
No
Further risk stratification
Proceed to OR and evaluate
postoperatively
Yes
Perioperative Pearls l Alraies l May 17, 2010
As the medical consultant, what is the MOST APPROPRIATE next step?1.
Com
plete a full preoperative evaluation, including a stress test, because she w
ill need a vascular procedure.
2.A
sk the patient about her physical activity so you can calculate her m
etabolic equivalents because she w
ill have an interm
ediate-risk surgery.
3.E
valuate her postoperatively for signs and sym
ptoms of a
myocardial infarction (M
I).
4.A
sk for surgery to be delayed for 2 days until a β
blocker low
ers her heart rate to betw
een 55 and 65 bpm
slowly.
Perioperative Pearls l May 17, 2010 l
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent? Operating RoomYes
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent? Operating RoomYes
Active cardiac condition?
NoEvaluate and TreatCardiac condition
Yes
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
ACC/AHA Guidelines•
Unstable coronary
syndromes
•D
ecompensated H
F
•S
ignificant arrhythm
ias–
High grade A
V block,
Mobitz II A
V block,
3rd degree AV
block, new
VT, sym
ptomatic
bradycardia, sym
ptomatic V
T, SV
T
with R
VR
•S
evere valvular heart disease
Fleisher LA et al. JACC 2007
Active cardiac conditions that require evaluation and treatment before noncardiac surgery
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent? Operating Room
Low-risk surgery?
Yes
Active cardiac condition?
NoEvaluate and TreatCardiac condition
Yes
No
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent? Operating Room
Low-risk surgery?
Yes
Active cardiac condition?
NoEvaluate and TreatCardiac condition
Yes
No
Operating RoomYes
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent?
Low-risk surgery?
Active cardiac condition?
No
No
Operating RoomYes
• Endoscopic procedures
• Superficial procedure
• Cataract• Breast
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent? Operating Room
Low-risk surgery?
Good (>4 METs)Functional capacity?
Yes
Active cardiac condition?
NoEvaluate and TreatCardiac condition
Yes
No
Operating RoomYes
No
Operating RoomYes
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Is surgery emergent?
Low-risk surgery?
Good (>4 METs)Functional capacity?
Active cardiac condition?
No
No
No
Operating RoomYes
Dress, toilet independently 1 METsWalk indoors around the house 2 METsLight housework, vacuum, laundry 3 METs Walk up a hill or a flight of stairs 4 METsGolf, bowling, dancing 6 METsTennis, running, swimming, basketball 8 METs
Cardiovascular Risk Assessment
Fleisher LA et al. JACC 2007
Perioperative Pearls l Alraies l May 17, 2010
Good (>4 METs)Functional capacity?
+3 Risk Factors 1-2 Risk Factors No Risk Factors
Operating RoomYes
No
Ischemic heart diseaseHeart failure
DiabetesRenal impairment
Cerebrovascular diseaseHigh risk surgery
Cardiovascular Risk Assessment
Fleisher LA et al. JACC 2007
Perioperative Pearls l Alraies l May 17, 2010
*Lee Cardiac Risk Index (RCRI)R
isk Ca
teg
ory
Even
t Rate
%C
lass I (0
pts)
0.5
Cla
ss II (1 pt)
1.3
Cla
ss III (2 pts)
3.6
Cla
ss IV (>
3 p
ts) 9.1
* Comprised of 6 factors: High-risk type surgery, ischemic heart disease, h/o CHF, h/o Stroke, Diabetes on Insulin, Cr>2.0mg/dl
Lee et al. Circulation 1999;100:1043
Perioperative Pearls l Alraies l May 17, 2010
Procedure Related Stress
Hig
h (R
epo
rted card
iac risk >5%
)
•E
merg
ent m
ajor o
peratio
ns
•A
ortic/vascu
lar surg
ery
•P
rolo
ng
ed su
rgical p
roced
ures; larg
e fluid
sh
ifts/blo
od
loss
Interm
ediate (R
epo
rted card
iac risk =1-5%
)
•C
arotid
end
arterectom
y
•H
ead an
d n
eck Su
rgery
•In
traperito
neal an
d in
tratho
racic Su
rgery
•O
rtho
ped
ic Su
rgery
•P
rostate S
urg
ery (oth
er than
TU
RP
)
Lo
w (R
epo
rted card
iac risk <1%
)
•E
nd
osco
pic p
roced
ures
•S
up
erficial pro
cedu
re
•C
ataract
•B
reast
•T
UR
P (b
ased o
n m
ost stu
dies, b
ut n
ot in
clud
ed
by A
CC
/AH
A)
Michota F, Frost S; Med Clin N Am 2002
Su
rgical S
tress Level
Perioperative Pearls l Alraies l May 17, 2010
Good (>4 METs)Functional capacity?
+3 Risk Factors 1-2 Risk Factors No Risk Factors
Operating RoomYes
No
Operating Room
Yes
Operating Room with heart rate control or noninvasive testing if it will change management
IntermediateRisk surgery
Vascularsurgery
Vascularsurgery
CoronaryAssessment
Fleisher LA et al. JACC 2007
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
What is the role for beta blockers and/or statins?
Depends on patient risk and
type of surgery
–V
ascular surgery patients
benefit from both
–Interm
ediate risk patients
do not benefit from statins
(DE
CR
EA
SE
-IV)
–D
ata is conflicting on the
role of beta-blockers in
intermediate risk patients
(PO
ISE
vs. DE
CR
EA
SE
-IV)
Perioperative Pearls l Alraies l May 17, 2010
POISE vs. DECREASE IV•
Both studies show
ed a
reduction in CV
events
•P
OIS
E had excess strokes
and overall mortality
•B
eta blocker doses and
timing w
ere different
–P
OIS
E (started just before surgery
with m
aximum
therapeutic dose
within 24 hours of surgery)
–D
EC
RE
AS
E (started 30 days
before surgery using 12.5% of
maxim
um therapeutic dose
Dunkelgrun M et al. Ann Surg 2009
Perioperative Pearls l Alraies l May 17, 2010
Good (>4 METs)Functional capacity?
+3 Risk Factors 1-2 Risk Factors No Risk Factors
Operating RoomYes
No
Operating Room
Yes
Operating Room with heart rate control or noninvasive testing if it will change management
IntermediateRisk surgery
Vascularsurgery
Vascularsurgery
CoronaryAssessment
Fleisher LA et al. JACC 2007
BB
SBB = Beta Blocker = Statin
S
BB
S
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Good (>4 METs)Functional capacity?
+3 Risk Factors 1-2 Risk Factors No Risk Factors
Operating RoomYes
No
Operating Room
Yes
Operating Room with heart ratecontrol or noninvasive testing
IntermediateRisk surgery
Michota FA. Ohio ACP 2009
BB
BB = Beta Blocker
>2 weeks preop
<2 weeks preop
Noninvasive testingif it will change management
Cardiovascular Risk Assessment
Perioperative Pearls l Alraies l May 17, 2010
Case 3 •A
75-yo p
rese
nts pre
op fo
r a
radical prostate
ctom
y for prostate
cancer. P
MH
x inclu
des C
AD
with
h/o
2-ve
ssel P
TC
A w
ith D
ES
sten
ting
8 m
on
ths
ag
o, H
TN
an
d
Typ
e 2
DM
. His curre
nt m
eds
include
: Insu
lin, A
teno
lol, AS
A, a
nd
clo
pid
og
rel. H
e is ve
ry active
swim
min
g several la
ps fo
r ab
out
30 m
inu
tes a
t lea
st 3 time
s per
we
ek; no
CP
but h
e doe
s ge
t SO
B.
•E
xam: P
=6
8, BP
=1
30
/75
, RR
=1
8
Lun
gs=
CTA
; hea
rt exam
is norm
al
exce
pt for a p
ara
doxica
l split S2
;
LE
pu
lses a
re no
rma
l.
•E
KG
= N
SR
, LA
HB
Perioperative Pearls l Alraies l May 17, 2010
Which of the following is the most appropriate recommendation at this time?
A.
Pro
cee
d to su
rgery o
n
clop
ido
grel an
d a
spirin
B.
Disco
ntinue
clopid
ogre
l an
d
proce
ed to surg
ery o
n a
spirin
C.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
now
D.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
with a
LM
WH
brid
ge
E.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
afte
r a four m
on
th dela
y
Perioperative Pearls l Alraies l May 17, 2010
Which of the following is the most appropriate recommendation at this time?
A.
Pro
cee
d to su
rgery o
n
clop
ido
grel an
d a
spirin
B.
Disco
ntinue
clopid
ogre
l an
d
proce
ed to surg
ery o
n a
spirin
C.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
now
D.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
with a
LM
WH
brid
ge
E.
Disco
ntinue
clopid
ogre
l an
d
asp
irin an
d pro
ceed
to su
rgery
afte
r a four m
on
th dela
y
Perioperative Pearls l Alraies l May 17, 2010
ACC/AHA Guidelines
Previous PCI
Balloon BMS DES
Time since PCI
<14d >14d >30-45d
<30-45d
<365d >365d
Delay for electiveor nonurgent surgery
Proceed to surgery on aspirin
Delay for electiveor nonurgent surgery
Proceed to surgery on aspirin
Fleisher LA et al. JACC 2007Grines CL et al. JACC 2007
Perioperative Pearls l Alraies l May 17, 2010
Case 4•
A 55
yo fe
male
with
h/o
CO
PD
(last FE
V1
=2L ~
1 yr a
go) H
TN
,
OA
and
obe
sity pre
sen
ts for p
reop
eva
luatio
n 2 w
ee
ks before
TAH
.
Sh
e has sm
oke
d 2
ppd
for the last
40yrs.
•H
er m
ed
s includ
e Ip
ratro
piu
m
/albute
rol inh
ale
r (wh
ich sh
e u
ses
spora
dically), HC
TZ
, an
d
ace
tamino
phe
n. S
he d
enie
s SO
B,
or co
ugh
.
•E
xam: P
=7
5, BP
= 1
30/8
0, RR
=1
8,
Sa
O2
=98
%. L
ung
s=d
ecre
ase
d a
ir
entry bilate
rally but n
o wh
eezing
.
He
art e
xam
is no
rma
l. Extre
mitie
s
are n
orm
al.
Perioperative Pearls l Alraies l May 17, 2010
What is the most appropriate next step in regards to addressing her perioperative pulmonary risk?
A.
Preoperative spirom
etry
B.
Re-education about daily
inhaler use
C.
Preoperative arterial blood
gas (AB
G)
D.
Preoperative sm
oking
cessation
E.
Chest radiography
F.A
ll of the above
Perioperative Pearls l Alraies l May 17, 2010
What is the most appropriate next step in regards to addressing her perioperative pulmonary risk?
A.
Preoperative spirom
etry
B.
Re-ed
ucatio
n ab
ou
t daily
inh
aler use
C.
Preoperative arterial blood
gas (AB
G)
D.
Preoperative sm
oking
cessation
E.
Chest radiography
F.A
ll of the above
Perioperative Pearls l Alraies l May 17, 2010
Preoperative Spirometry
•N
o evidence for risk
prediction perioperatively
•N
o threshold of values for
which surgery is
contraindicated
•C
onsensus
–Lung R
esection
–C
AB
G
–U
nexplained dyspnea or lung
disease
ACP Guidelines for PFT’s. Ann Intern Med 1990;112:793-4Qaseem A et al. Ann Intern Med 2006
Perioperative Pearls l Alraies l May 17, 2010
Risk factors for Postoperative Pulmonary Complications
•P
atient–
CO
PD
–A
ge
>60
yrs
–A
SA
cla
ss >
II
–F
un
ctio
nal
de
pe
nd
enc
e
–C
HF
–A
lbu
min
<3
.5g/d
L
•P
rocedure–
>3
ho
urs
du
ratio
n,
ge
ne
ral a
ne
sthe
sia
, e
me
rge
nc
y su
rge
ry
–T
ho
racic, v
asc
ula
r, h
ead
and
nec
k,
ne
uro
su
rgic
al, a
nd
a
bd
om
ina
l p
roce
du
res
Qaseem A et al. Ann Intern Med 2006
Perioperative Pearls l Alraies l May 17, 2010
Risk factors for Postoperative Pulmonary Complications
•P
atient–
CO
PD
–A
ge
>60
yrs
–A
SA
cla
ss >
II
–F
un
ctio
nal d
ep
en
de
nce
–C
HF
–A
lbu
min
<3
.5g/d
L
•P
rocedure–
>3
ho
urs
du
ratio
n, g
en
era
l a
nes
thes
ia, e
me
rge
nc
y
su
rge
ry
–T
ho
racic, v
asc
ula
r, he
ad
a
nd
ne
ck, n
eu
rosu
rgic
al, a
nd
ab
do
min
al p
roc
ed
ure
s
Qaseem A et al. Ann Intern Med 2006
Smoking data is mixed
Obesity and mild to moderate asthma are not associated with increased risk
Perioperative Pearls l Alraies l May 17, 2010
Preoperative Pulmonary Risk-Reduction Strategies
•S
moking cessation (>
6-8
wks)
•R
educe airway obstruction
–S
trict ad
here
nce
to
prescrib
ed m
edica
tion
s
–P
reop
era
tive stero
ids a
s
nee
de
d
•A
ntibiotics for respiratory
infection
•P
reoperative lung
expansion education
–Ince
ntive sp
irom
etry
Smetana GW et al. N Engl J Med 1999 Qaseem A et al. Ann Intern Med 2006
Perioperative Pearls l Alraies l May 17, 2010
Postop Pulmonary Risk-Reduction Strategies•G
oo
d evid
ence
of b
en
efit
–P
osto
perative lu
ng
expan
sion
m
od
alities (A)
–Incentive spirom
etry, CP
AP
–S
elective po
stop
erative naso
gastric
deco
mp
ression
(B)
–S
ho
rt-acting
neu
rom
uscu
lar blo
ckade
(B)
•E
quivoca
ble e
vide
nce o
f ben
efit
–L
aparo
scop
ic (vs. op
en) o
peratio
n (C
)
•C
on
flicting evide
nce
of b
ene
fit vs. ha
rm
–S
mo
king
cessation
(I)
–In
traop
erative neu
raxial blo
ckade (I)
–P
osto
perative ep
idu
ral analg
esia (I)
–Im
mu
no
nu
trition
(I)
•C
lear e
viden
ce of h
arm
–R
ou
tine to
tal paren
teral or en
teral n
utritio
n (D
)
–R
igh
t-heart cath
eterization
(D)
Lawrence VA et al. Ann Int Med 2006
Perioperative Pearls l Alraies l May 17, 2010
Anticoagulation and Surgery
Perioperative Pearls l Alraies l May 17, 2010
Case 6•
72-ye
ar-old w
oman
with h
istory of
rheu
matic h
eart
dise
ase, a
trial
fibrilla
tion
an
d s/p
me
chan
ical a
ortic
valve is now
sche
duled
for an
ele
ctive sigm
oid
rese
ction fo
r colo
n
cancer.
•P
atie
nt is on w
arfarin
with targe
t INR
2.0-
3.0
.
Perioperative Pearls l Alraies l May 17, 2010
What are your recommendations for perioperative anticoagulation?
A.
Stop w
arfarin 5 days before
surgery and resume w
arfarin on
the morning of surgery
B.
Stop w
arfarin 5 days before, use
SC
full dose LMW
H starting 3
days before surgery; resume full
dose LMW
H w
ith warfarin post-
operatively until the INR
is
between 2 - 3
C.
Use F
FP
and IV V
itamin K
to
reverse the effect of warfarin in
the AM
of surgery and then
proceed with surgery
D.
Stop w
arfarin 5 days before, start
IV U
FH
the same day; resum
e IV
UF
H w
ith warfarin post-operatively
until the INR
is between 2 - 3
Perioperative Pearls l Alraies l May 17, 2010
What are your recommendations for perioperative anticoagulation?
A.
Stop w
arfarin 5 days before
surgery and resume w
arfarin on
the morning of surgery
B.
Stop w
arfarin 5 days before, use
SC
full dose LMW
H starting 3
days before surgery; resume full
dose LMW
H w
ith warfarin post-
operatively until the INR
is
between 2 - 3
C.
Use F
FP
and IV V
itamin K
to
reverse the effect of warfarin in
the AM
of surgery and then
proceed with surgery
D.
Stop w
arfarin 5 days before, start
IV U
FH
the same day; resum
e IV
UF
H w
ith warfarin post-operatively
until the INR
is between 2 - 3
Perioperative Pearls l Alraies l May 17, 2010
Thrombosis Risk “Window”•
A therapeutic patient (IN
R 2-3)
will generally need 5 days off
OA
C to low
er the INR
to this level
–P
re-proce
dura
l “win
dow
” of
thrombo
sis risk
•T
herapeutic OA
C w
ill take
another 3-4 days after the
procedure
–P
ost-p
rocedu
ral “w
ind
ow” o
f
thrombo
sis riskWhite RH et al. Arch Intern Med. 1995
Perioperative Pearls l Alraies l May 17, 2010
Who needs bridging therapy?
Perioperative Pearls l Alraies l May 17, 2010
•N
o randomized
controlled trials
•E
xpert opinion
Perioperative Pearls l May 17, 2010 l
Perioperative Pearls l Alraies l May 17, 2010
Anticoagulation and Surgery
Perioperative Pearls l May 17, 2010 l
Bleeding Thrombosis
surgery
Perioperative Pearls l Alraies l May 17, 2010
Communication
•C
onsultant
•S
urgeon
•A
nesthesia
•N
ursing staffPerioperative Pearls l May 17, 2010 l
Perioperative Pearls l Alraies l May 17, 2010
INR 1.5-2.0
INR>2.0 INR>2.0
INR 1.5-2.0
INR<1.5
Procedure
OAC stopped
OAC started
Days 0-5
1 5
Thrombosis Risk “Window”
Perioperative Pearls l Alraies l May 17, 2010 Perioperative Pearls l May 17, 2010 l
CHADS2 Score:1. Recent CHF =12. Age ≥ 75 years =13. Diabetes mellitus =14. Prior stroke or TIA =2 Kearon C et al. N Eng J Med 1997
Gage J et al. JAMA 2001
Perioperative Pearls l Alraies l May 17, 2010
UFH Bridge Protocol
INR>2.0 INR>2.0
Procedure
OAC stopped
OAC started
Days 0-5
1 5
Begin IVUFH
Stop IVUFH Begin IVUFH*
Stop IVUFH
1 Week LOS
Perioperative Pearls l Alraies l May 17, 2010
LMWH Bridge Protocol
INR>2.0 INR>2.0
Procedure
OAC stopped
OAC started
Days 0-5
1 5
Begin LMWH
Stop LMWH* Begin LMWH*
Stop LMWH
1-2 Day LOS
Perioperative Pearls l Alraies l May 17, 2010
Post-operative AC management consideration
• Close communication with surgeon and patient
• Monitor hemostasis, hematology and chemistry lab closely
• Start warfarin and prophylactic AC as soon as feasible (within 24 hours)
• Avoid LMWH with impaired renal function (CrCl < 30 ml/min) / high risk bleeding surgery (neuro and cardiac)
• Full dose AC with 24 hours for moderate risk and 48-72 for high risk for bleeding surgery.
• Fondaparinux is not recommended for bridging AC.
Perioperative Pearls l May 17, 2010 l