Transcript Grade 1A - Welcome to ISA Pondicherry | Indian Society of

PERIOPERATIVE MANAGEMENT OF
PATIENTS ON ANTI THROMBOTIC
THERAPY
DR. V. R. Hemanth Kumar
Asst prof
MGMC&RI
American College of Chest Physicians Guidelines-2008
Douketis etal
American Society of Regional Anaesthesia guidelines 2009
Horlocker etal
Summary of
Recommendations
Grade 1A
Strong recommendation, high-quality evidence,
Desirable effects clearly outweigh undesirable effects, or vice versa
Consistent evidence from RCTs without important limitations or exceptionally
strong evidence from observational studies
Recommendation can apply to most patients in most circumstances; further
research is very unlikely to change our confidence in the estimate of effect
Grade 1B
Strong recommendation, moderate-quality evidence,
Desirable effects clearly outweigh undesirable effects, or vice versa
Evidence from RCTs with important limitations (inconsistent results,
methodological flaws, indirect or imprecise), or very strong evidence from
observational studies
Recommendation can apply to most patients in most circumstances; higher
quality research may well have an important impact on our confidence in the
estimate of effect and may change the estimate
Grade 1C
Strong recommendation, low or very low-quality evidence,
Desirable effects clearly outweigh undesirable effects, or vice versa
Evidence for at least one critical outcome from observational studies, case series,
or from RCTs with serious flaws or indirect evidence
Recommendation can apply to most patients in many circumstances; higherquality research is likely to have an important impact on our confidence in the
estimate of effect and may well change the estimate
Grade 2A
Weak recommendation, high-quality evidence,
Consistent evidence from RCTs without important limitations or exceptionally
strong evidence from observational studies
The best action may differ depending on circumstances or patient or society
values;
further
research
very unlikely
to change our
confidence in the estimate
Desirable
effects
closely is
balanced
with undesirable
effects
of effect
Grade 2B
Weak recommendation, moderate-quality evidence,
Desirable effects closely balanced with undesirable effects
Evidence from RCTs with important limitations (inconsistent results,
methodological flaws, indirect or imprecise), or very strong evidence from
observational studies
Best action may differ depending on circumstances or patient or society values ;
higher-quality research may well have an important impact on our confidence in
the estimate of effect and may change the estimate
Grade 2C
Weak recommendation, low or very low-quality evidence,
Desirable effects closely balanced with undesirable effects
Evidence for at least one critical outcome from observational studies, case series,
or from RCTs with serious flaws or indirect evidence
Other alternatives may be equally reasonable; higher-quality research is likely to
have an important impact on our confidence in the estimate of effect and may
well change the estimate
ACCP recommend stopping
warfarin approximately 5
days before surgery to allow
adequate time for the INR to
normalize (Grade 1B).
ACCP recommend
resuming warfarin
approximately 12 to 24hrs
after surgery (Grade 1C).
In patients whose INR is still elevated (ie, > 1.5)
1 to 2 days before surgery. what to do?
ACCP suggest administering low-dose
(ie, 1 to 2 mg) oral vitamin K to
normalize the INR (Grade 2C).
Choice of Bridging anticoagulants
Based on risk for
thromboembolism
Three subsets
Patients With a Mechanical Prosthetic
Heart Valve
With Chronic Atrial Fibrillation
Patients With Prior VTE
Patients With a Mechanical Prosthetic Heart Valve
High Risk
a mitral valve
prosthesis
an older-generation
aortic valve prosthesis
Moderate
Risk
Bi leaflet aortic
valve prosthesis
and one of the
following
1.AF,
2.Prior stroke or
TIA
within 6 months stroke
or TIA
Low Risk
Bi leaflet aortic
valve prosthesis
without atrial
fibrillation
No other risk
factors for
stroke.
3.other stroke risk factors (hypertension,
diabetes, congestive heart failure, age 75
years
With Chronic Atrial Fibrillation
High Risk
CHADS2 score of 5 or 6;
within 3
months stroke
or TIA
rheumatic
valvular heart
disease
Moderate
Risk
CHADS2 score
of 3 or 4,
Low Risk
CHADS2 score
of 0 to 2
No prior stroke
or transient
ischemic attack
Patients With Prior VTE
High Risk
Moderate
Risk
Low Risk
Prior VTE within 3 months
prior VTE
within the past
3 to 12 months
VTE occurred
12 months ago
severe
thrombophilic
conditions
non severe
thrombophilic
conditions
no risk factors
active cancer
LMWH
Prophylactic LMWH- Dalteparin5000U SC OD OR
Enoxaparin 40mg SC od
Therapautic dose- enoxaparin 1mg/kg every 12
hrs, enoxaparin 1.5 mg/kg daily, dalteparin 120
U/kg every 12 hrs, dalteparin 200 U/kg daily,
tinzaparin 175 U/kg daily
UFH
Prophylactic dose UFH-5000U SC BD /TID
Therapautic dose-5,000 U IV bolus followed by
32,000 U q24h by IV infusion or 35,000 to
40,000 U q24h sc, adjusted to maintain APTT in
the therapeutic range1.5 times control
Bridging anticoagulant of choice for high risk cases?
ACCP recommend bridging
anticoagulation with therapeuticdose SC LMWH or IV UFH (Grade
1C). therapeutic-dose SC LMWH
is preferred over IV UFH (Grade
2C).
Bridging anticoagulant of choice for moderate risk cases?
ACCP suggest bridging anticoagulation
with therapeutic-dose SC LMWH,
therapeutic-dose IV UFH, or low-dose
SC LMWH (Grade 2C);ACP suggest
therapeutic-dose SC LMWH over
other management options (Grade
2C)
Bridging anticoagulant of choice? for low risk cases
ACCP suggest lowdose SC LMWH or no
bridging (Grade 2C).
Values and preferences
In patients at high or moderate risk for thrombo
embolism, the recommendations reflect a relatively
high value on preventing thrombo embolism and a
relatively low value is on preventing bleeding;
in patients at low risk for thrombo embolism, the
recommendations reflect a relatively high value on
preventing bleeding and a relatively low value on
preventing thrombo embolism.
Cost containment perspective
ACCP recommend the use of SC
LMWH administered in an
outpatient setting where feasible
instead of inpatient
administration of IV UFH (Grade
1C)
When to stop bridging
anticoagulant –
therapeutic dose
LMWH
administer the last dose of LMWH 24 h before surgery
(Grade 1C);
last preoperative dose of LMWH is approximately half
the total daily dose
In patients who are receiving bridging anticoagulation
with therapeutic-dose IV UFH, ACCP recommend
stopping UFH approximately 4 h before surgery
(Grade 1C).
When to restart therapeutic dose LMWH
In patients undergoing a minor
surgical procedure and who are
receiving bridging anticoagulation
with therapeutic- dose LMWH, ACCP
recommend resuming this regimen
approximately 24 h after the
procedure (Grade 1C).
In patients undergoing major surgery for whom
postoperative therapeutic-dose LMWH/UFH is
planned, ACCP recommend either
1. delaying the initiation of therapeutic-dose
LMWH/UFH for 48 to 72 h after surgery when
hemostasis is secured, or
2. administering low-dose LMWH/UFH after
surgery when hemostasis is secured, or
3.completely avoiding LMWH or UFH after
surgery (Grade 1C)
Is it necessary to monitor anticoagulant effect of
LMWH with anti-factor Xa levels
ACCP suggest against the
routine use of anti-factor
Xa levels to monitor the
anticoagulant effect of
LMWHs (Grade 2C).
When to stop asprin and clopidogrel if required?
In patients who require temporary
interruption of aspirin or
clopidogrel-containing drugs before
surgery, ACCP suggest stopping this
treatment 7 to 10 days before the
procedure (Grade 2C).
ACCP suggest resuming aspirin
and clopidogrel approximately
24 h after surgery when there
is adequate hemostasis (Grade
2C).
Is it necessary to monitor antithrombotic activity of
asprin or clopidogrel
ACCP suggest against the
routine use of platelet function
assays to monitor the
antithrombotic effect of aspirin
or clopidogrel (Grade 2C).
What are Not at increased risk for cardiovascular events
drugs for Primary prevention of MI or Stroke
What are at increased risk for cardiovascular events
recent placement of bare metal stent or drug
eluting stent and MI with in 3 months
Guidelines for not high risk & high risk
For patients who are not at high risk for cardiac events,
ACCP recommend interruption of antiplatelet drugs
(Grade 1C).
For patients at high risk of cardiac events scheduled for
non cardiac surgery, ACCP suggest continuing aspirin up
to and beyond the time of surgery (Grade 2C); if patients
are receiving clopidogrel, we suggest interrupting
clopidogrel at least 5 days and, preferably, within 10 days
prior to surgery (Grade 2C).
Recommendations
for CABG and PCI
In patients scheduled for CABG, ACCP recommend continuing
aspirin up to and beyond the time of CABG (Grade 1C); if aspirin
is interrupted(some institutions for increased risk of mediastinal
bleeding), ACCP recommend it be reinitiated between 6 h and48
h after CABG (Grade 1C).
Stop clopidogrel at least 5 days and, preferably, 10days prior to
surgery (Grade 1C).
In patients scheduled for PCI, ACCP suggest continuing aspirin up
to and beyond the time of the procedure; (better to continue
clopidogrel but no recommendation) if clopidogrel is interrupted
prior to PCI, ACCP suggest resuming clopidogrel after PCI with a
loading dose of 300 to 600 mg (Grade 2C).
Recommendations
for bare metal and
drug eluting stent
In patients with a bare metal coronary stent
who require surgery within 6 weeks of stent
placement, ACCP recommend continuing
aspirin and clopidogrel in the perioperative
period (Grade 1C).
In patients with a drug-eluting coronary stent
who require surgery within 12 months of
stent placement, ACCP recommend
continuing aspirin and clopidgrel in the
perioperative period (Grade 1C).
Is bridging therapy required after stopping antiplatelet
drugs?
ACCP suggest against the routine
use of bridging therapy with
UFH, LMWH, direct thrombin
inhibitors, or glycoprotein IIb/IIIa
inhibitors (Grade 2C).
In patients who are undergoing minor procedures and are receiving
warfarin, ACCP recommend continuing warfarin around the time of
the procedure co administering an oral prohemostatic agent (Grade
1B for dental and Grade 1C for dermatological and cataract
surgeries
In patients who are undergoing minor procedures and are receiving
aspirin, ACCP recommend continuing aspirin around the time of the
procedure (Grade1C).
In patients who are undergoing minor procedures and are receiving
clopidogrel, continuation or stopping is based on situation.
patients on warfarin coming as emergency
For less immediate reversal of the anticoagulant
effect, ACCP recommend treatment with low-dose
(2.5 to 5.0 mg) IV or oral vitamin K (Grade 1C).
For more immediate reversal of the anticoagulant
effect, ACCP suggest treatment with fresh-frozen
plasma or another prothrombin concentrate in
addition to low-dose IV or oral vitamin K (Grade 2C).
Perioperatively life threatening bleeding occurs in
patients on aspirin and clopidogrel
ACCP suggest platelet
transfusion or
prohemostatic agents
(Grade 2C).
Recent guidelines focused not only on neuraxial
blocks and anticoagulants but also focussed on
thromboprophylaxis perioperatively.
And also focused on peripheral blockade.
Regional anaesthesia given –for how
many days fibrinolytic drugs are avoided
avoid fibrinolytic drugs
for 10 days after puncture
of non compressible
vessels (Grade 1A).
Fibrinolytic drugs given-for how many days regional
anesthesia is avoided
ASRA recommend against performance of
spinal or epidural anesthetics except in highly
unusual circumstances(Grade 1A).
Data are not available to clearly outline the
length of time neuraxial puncture should be
avoided after discontinuation of these drugs.
who have received neuraxial blocks at or near the time
of fibrinolytic therapy - postoperative management
neurological monitoring should be continued .
epidural catheter infusion, should be limited to drugs
minimizing sensory and motor block to facilitate
assessment of neurologic function (Grade 1C).
Any recommendation to remove catheter
There is no definitive
recommendation for removal of
neuraxial catheters in patients
who unexpectedly receive
fibrinolytic therapy during a
neuraxial catheter infusion.
how to evaluate residual thrombolytic effect in such
cases
ASRA suggest for the measurement of
fibrinogen level (one of the last clotting
factors to recover)
1. To evaluate the presence of residual
thrombolytic effect
2.For appropriate timing of catheter
removal (Grade 2C).
For Patients receiving prophylactic
dose of <10000 U SC UFH daily
no contraindication for
neuraxial technique
(Grade 1C).
For Patients receiving >10000 U SC UFH
may have an increased risk of surgical-related
bleeding.
But unclear whether there is an increased risk of
spinal hematoma.
techniques to facilitate detection of
new/progressive neurodeficits like neurologic
monitoring and neuraxial solutions to minimize
sensory and motor block should be applied (Grade
2C).
Patients coming for surgery after receiving heparin
for more than 4 days
Because of risk of heparininduced thrombocytopenia,
platelet count should be assessed
before neuraxial block and
catheter removal (Grade 1C).
Combining neuraxial techniques
with intraoperative
anticoagulation with intravenous
UFH during vascular surgery is
acceptable with the following
recommendations (Grade 1A)
IV UFH-4 hrs-neuraxial procedure-1 hr- IV UFH
1.Needle placement and /or catheter
putting or removal should be done 2 to
4 hrs after the last heparin dose
2.assess the patient’s coagulation status
3.re-heparin 1 hr after neuraxial
technique.
bloody or difficult neuraxial needle
placement. cancellation of case?
there is no data to support mandatory
cancellation of a case.
Direct communication with the surgeon and a
specific risk-benefit decision about proceeding
in each case is warranted.
Postoperative monitoring in such cases
Monitor the patient postoperatively to
provide early detection of motor
blockade
consider use of minimal concentration
of local anesthetics to enhance the
early detection of a spinal hematoma.
Pre op single daily dosing
needle placement should occur at least 10 to 12 hrs
after the prophylactic /single LMWH dose (Grade 1C).
Pre op twice daily dosing
needle placement should occur at least 24 h after the
therapeutic LMWH twice daily dose (Grade 1C).
POSTOP LMWH single daily dosing
The first postoperative LMWH dose should be
administered 6 to 8 hrs postoperatively.
The second postoperative dose should occur no sooner
than 24 hrs after the first dose.
However, the catheter should be removed after a
minimum of 10 to 12 hrs after the last dose of LMWH.
Subsequent LMWH dosing should occur after a minimum
of 2 hrs after catheter removal.
Postoperative LMWH twice daily dosing
This dosage regimen is associated with an increased risk
of spinal hematoma.
The first dose of LMWH should be administered no earlier
than 24 hrs postoperatively,
the epidural catheter must be removed before the first
dose of LMWH. Administration of LMWH should be
delayed for 2 hrs after catheter removal.
prophylactic LMWH-12 hrs-neuraxial
technique -6hrs-1st post op prophylactic
LMWH dose-24 hrs-2nd dose
LMWH-12 hrs- Catheter removal-2hrsLMWH
Therapeutic LMWH-24 hrs-neuraxial
technique-22 hrs-catheter removal-2hrsTherapeutic LMWH
monitoring of the anti-Xa level. is it necessary?
ASRA recommend against the routine use of
monitoring of the anti-Xa level (Grade 1A).
The presence of blood during needle and catheter
placement. does it necessitate postponement of
surgery?
No.
Initiation of LMWH therapy in this setting should
be delayed for 24 hrs postoperatively
this consideration should be discussed with the
surgeon (Grade 2C).
Warfarin to be stopped ideally
4 to5 days before the planned
procedure and the INR must be
normalized before initiation of
neuraxial block (Grade 1B).
NSAID including asprin no contraindication for
neuraxial block-(Grade 1A).
Contradiction to ACCP guidelines where surgical bleed
was discussed and so aspirin stopped 7-10 days before
Discontinue clopidogrel 7 days before neuraxial block(Grade 1C).
Platelet GP IIb/IIIa inhibitors
Neuraxial techniques should be avoided until platelet
function has recovered ie
24 to 48 hrs for abciximab
4 to 8 hrs for eptifibatide and tirofiban
Although GP IIb/IIIa antagonists are contraindicated within 4
weeks of surgery, should one be administered in the postoperative
period (after a neuraxial technique), patient should be carefully
monitored neurologically
Herbal medications
Should we stop herbal medications preoperatively
ASRA recommend against
mandatory discontinuation
of these medications (Grade
1C).
Same recommendations
applied for neuraxial
techniques can be applied
(Grade 1C).
Thank
you