Perioperative Anticoagulation Management Publications (568)
Perioperative Anticoagulation Management Publications
In this review, we performed an extensive literature search summarizing the management of patients on direct-acting anticoagulants in the perioperative period. A total of four direct-acting oral anticoagulants were considered appropriate for inclusion in this review. The drugs were dabigatran etexilate mesylate (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Management of patients on DOACs in the perioperative period involves an assessment of thromboembolic event risk while off anticoagulation compared to the relative risk of bleeding if such drug is continued. DOACs may not need to be discontinued in minor surgeries or procedures, and in major surgeries, they may be discontinued hours prior depending on drug pharmacokinetics and renal function of the patients.
Accordingly, an optimized therapy prior to, during, and after surgery will likely influence not only the immediate postoperative course but also hospital mortality and long-term outcome. Publications on the topic of perioperative management of geriatric patients are fortunately gaining in quality and quantity, not least against the background of the demographic developments. Accordingly, specific influencing factors relevant for perioperative management can be increasingly more identified. This short review summarizes the current state of knowledge to provide an overview and rationale for clinical decision making.
HCRU outcome measures evaluated in the first 90 patients enrolled were use of blood products and pro-hemostatic agents, length of stay (LOS) in hospital, and LOS in intensive care unit (ICU).
Blood products or pro-hemostatic agents were given to 63% (32/51) of patients in Group A and 23% (9/39) of patients in Group B on the day of/day after surgery. An overnight hospital stay was reported for 82% (42/51) of patients in Group A with median LOS = 7 (range = 1-71) bed-days. For Group B, 92% (36/39) had an overnight hospital stay with a median LOS = 9 (range = 1-92) bed-days. In Group A, 17 patients were admitted to the ICU for at least 1 day with median LOS = 4 (range = 1-44) days; in Group B the number was 15 with median LOS = 2 (range = 1-92) days.
The lack of a control group and the small patient numbers limit the strength of the conclusions.
The use of idarucizumab may simplify emergency management of dabigatran-treated patients with life-threatening bleeds and reduce perioperative complications in patients undergoing emergency surgery.
Multiple authors have suggested cut-offs leading to ambiguity among practicing clinicians. Recent data pertaining to systemic thromboembolism, stroke and major bleeding derived from randomized controlled clinical trials have simplified the periprocedural management of NOACs. This review focusses on heterogeneity in the management of NOACs in patients with CKD in this peculiar scenario and highlights the contemporary evidence to support a unified approach towards perioperative management of NOACs. Multiple antidotes targeted towards binding of specific NOACs have been developed and are in the testing phase, thereby offering immense potential for rapid and complete reversal of NOAC activity in emergent procedures and major bleeding episodes. Targeted research on thromboembolism, stroke and major bleeding following temporary periprocedural interruption of NOACs using multicentric registries could further expand the clinical utility of these agents.
The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery.
Out of all members (n = 2000) of the Endourological Society, 133 participated in our survey. Eighty-eight percent of the participants indicated to perform transurethral therapy of BPO on ongoing OA, whereas 60% of this group temporarily pause the OA during the intervention. Sixteen percent perform >30 transurethral interventions of BPO on ongoing OA per year. Most operations are performed under continuation of aspirin (58.2%). The continuation of adenosine diphosphate (ADP)-receptor inhibitors (22.1%), vitamin K antagonists (18.9%), factor Xa inhibitors (15.6%), or the combination of two oral anticoagulants (16.4%) is continued less often. The decision for the operation on ongoing OA is usually approved by the cardiologist (58%) or it cannot be stopped in case of emergency (29%). GreenLight laser (39%) was the most frequently used technique on ongoing OA, followed by monopolar or bipolar transurethral resection of the prostate (35%) as well as other sources of laser [holmium (12%), thulium (12%), diode laser (2%)]. Although OA was continued during the interventions, cardiovascular complications were observed in 31.6%.
Current practice shows that the majority of a representative group of the Endourological Society members perform transurethral therapy of BPO in patients on ongoing OA. The incidence of perioperative complications under transurethral therapy of BPO on ongoing OA is lower than previously assumed.
Relative risks (RRs) with 95% confidence intervals (CI) were estimated.
A total of 39 studies were enrolled in this review. Patients with pharmacological thromboprophylaxis had a relatively reduced incidence of deep venous thrombosis (DVT) compared with those without (0.5% vs 1.2%, RR 0.51, 95% CI 0.27-0.94; P = 0.03) but a significantly increased incidence of bleeding events (RR 2.51, 95% CI 1.79-3.51; P < 0.0001). The incidence of pulmonary embolism (PE) (RR 1.77, 95% CI 0.76-4.14; P = 0.19) and mortality related to venous thromboembolism (VTE) (1/2,811 vs 2/3,380) were similar between the pharmacological thromboprophylaxis group and the no pharmacological thromboprophylaxis group. Low-molecular-weight heparin (LMWH) reduced the incidence of DVT compared with unfractionated heparin (UFH) (RR 0.81, 95% CI 0.66-1.00; P = 0.05), and standard extended thromboprophylaxis after cancer surgery significant decreased the incidence of DVT as compared with conventional thromboprophylaxis (RR 0.57, 95% CI 0.39-0.83; P = 0.003).
Routine pharmacological thromboprophylaxis for cancer patients undergoing surgery needs to be carefully considered, because although thromboprophylaxis is associated with lower VTE events, there is a higher incidence of clinically significant bleeding events. If pharmacological thromboprophylaxis is to be used, extended thromboprophylaxis started preoperatively with LWMH might be the most effective strategy.
A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014 through January 2, 2015 was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls.
Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. 61 patients (27.48%) called regarding pain control. 54 patients (23.87%) called with bathing/dressing/wound questions. Other common categories include: other (21.17%), medication problems (15.77%), weight bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased BMI (p=0.031), lower number of comorbidities (p=0.043), telephone call within two weeks prior to surgery (p=0.027), American Society of Anesthesiology (ASA) score of 2 (p=0.036), discharge disposition to home (p=0.003), and elective procedure (p=0.006). Multivariate analysis revealed that fusion procedures (OR: 2.16, 95% CI: 1.05 - 4.45, p = 0.037) and ASA score of 3-4 (OR: 0.55, 95% CI: 0.31 - 0.96, p = 0.036) were independently associated with increased and decreased propensity, respectively, towards making a phone call within two weeks.
Postoperative patient-initiated telephone calls within 14 days following spine surgery are very common, occurring after almost half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.