Perioperative Management of Oral Anticoagulation

Patients with mechanical heart valve replacement require lifelong anticoagulation therapy, and additional surgeries can pose a risk of bleeding and thromboembolic events due to the need for perioperative anticoagulation management. Here, we present a case report of a patient who underwent laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) after mechanical heart valve replacement and experienced postoperative cerebral embolism. The management of perioperative anticoagulation in these patients is discussed, including strategies for minimizing the risks of bleeding and thromboembolic events during and after surgery.

Performance of large language models and clinical decision support in perioperative management of oral anticoagulants.

Comparative Analysis of Perioperative Anticoagulation Management Guidelines across U.S. Institutions

Letters15 January 1997Prevention of Venous Thrombosis in Knee ArthroplastyLorne Basskin, PharmDLorne Basskin, PharmDButler University, Indianapolis, IN 46260Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-126-2-199701150-00018 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:In a randomized, double-blind trial, Leclerc and colleagues [1] concluded that postoperative, fixed-dose exoxaparin is more effective than adjusted-dose warfarin in the prevention of deep venous thrombosis after knee arthroplasty. However, I do not believe that their conclusions and recommendations are justified.As a reference value, Leclerc and colleagues cited incidences of deep venous thrombosis without prophylaxis ranging from 55% to 70%. However, it is my understanding that these values relate to earlier years, in which the standard of care did not include early ambulation of the patient. Is it not possible that the incidence today, without ...REFERENCE1. Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, l'Esperance B, Demers C, et al. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med. 1996; 124:619-26. Google Scholar Author, Article, and Disclosure InformationAffiliations: Butler University, Indianapolis, IN 46260 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byLow-Dose Warfarin for Prevention of Symptomatic Thromboembolism after Orthopedic Surgery 15 January 1997Volume 126, Issue 2Page: 172-173KeywordsArthroplastyDeep vein thrombosisDrugsHeparinInternational normalized ratioKneesProphylaxisPulmonary embolismSurgeryWalking Issue Published: 15 January 1997 Copyright & PermissionsCopyright © 1997 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.

Direct oral anticoagulants (DOACs) are in wide use among patients requiring both short- and long-term anticoagulation, mainly due to their ease of use and the lack of monitoring requirements. With growing use of DOACs, it is imperative that physicians be able to manage patients on these medications, especially in the perioperative period. We aim to provide guidance on the management of DOACs in the perioperative period. 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.

Objective To investigate high risk factors, early diagnosis and prevention of cerebral venous sinus thrombosis (CVST). Methods The clinical features of cerebral venous sinus thrombosis as well as imaging examination results of 425 pregnant women with cerebral venous sinus thrombosis(hospitalization time was 1 to 90 days, average hospitalization time was 24.33 days) were searched from VIP Database and Chinese Journal Full-Text Database (CJFD) from 1989 to 2009. They were divided into three groups according to the onset of cerebral venous sinus thrombosis. There had no statistical significance of age, hospitalization time, treatment measures, and degrees of cerebral venous sinus thrombosis among three groups (P>0.05). High risk factors, clinical features, imaging changes and prognosis of cerebral venous sinus thrombosis were analyzed to discuss the way of early diagnosis and prevention. Results Preeclampsia, cesarean section, postpartum hemorrhage(PPH) were the most common risk factors of cerebral venous sinus thrombosis of pregnant women. The misdiagnosis rates of cerebral venous sinus thrombosis in early, middle and late pregnancy were 100.00% and 65.63%, respectively. The postpartum misdiagnosis rate and mortality were 29.8% and 8.6%, respectively. The positive rates of graphical changes were 54.42% and 94.04%-100% by CT and MRI/MRV inspection, respectively. Conclusion Pre-pregnancy and two weeks after delivery are susceptible to cerebral venous sinus thrombosis compared with other periods. Misdiagnosis rate is extremely high during early pregnancy, which can not be ignored. The key to prevent cerebral venous sinus thrombosis are early intervention and more attention to high risk factors. The suspected patients in prenatal and labor stage should undergo MRV inspection in order to confirm the diagnosis, conduct early treatment to reduce mortality and disability. Key words: cerebral venous sinus thrombosis(CVST); pregnant women; high risk factors; early diagnosis; prevention

AHA Scientific Statement: Guide to anticoagulant therapy: heparin: a statement for healthcare professionals from the American Heart Association.

Venous thromboembolism (VTE) is a known possible complication of surgical procedures. In early studies, the incidence of fatal pulmonary embolism, in the absence of prophylaxis, was estimated to be 0.1–0.8 % in patients undergoing elective general surgery, 2–3 % in patients having elective total hip replacement, and 4–7 % of patients undergoing surgery for a fractured hip. The risk for VTE in surgical patients is determined by the combination of patient-related predisposing factors (discussed below) and the specific type of surgery (time length of immobilization, degree of invasiveness, time of postoperative hospitalization). Evidence-based guidelines have been published for VTE prevention as well as for management of patients currently receiving anticoagulation for prior deep vein thrombosis (DVT) or pulmonary embolism (PE) in the perioperative period. The risk of new or recurrent VTE versus the risk of perioperative bleeding while on anticoagulation should be discussed with the surgeon so that a multidisciplinary decision can be made about perioperative anticoagulation management.

We report the results of a double-blind, randomised trial of venous thrombosis (VT) prevention in 117 patients having elective hip replacement where low dose heparin alone (5,000 IU sodium heparin given subcutaneously [sc] 8 hourly until the seventh postoperative day) was compared with low dose heparin plus dihydroergotamine (DHE; 0.5 mg, given 8 hourly by sc injection). The trial end point consisted of VT discovered through bilateral ascending venography done routinely on the seventh postoperative day. VT developed in 34% of patients given heparin/DHE (95% confidence interval = 22% - 47%) compared with 24% in those given low dose heparin alone (95% confidence interval = 14% - 37%; p = 0.34), difference = 10% (95% confidence interval = -7% to +26%). Corresponding figures for the incidence of proximal (above-knee) thrombosis were 17% and 14% (95% confidence intervals = 8% - 29% and 6% - 25% respectively). These results are discussed in the context of a detailed overview of published evidence concerning VT prevention with heparin/DHE after hip replacement and we conclude it is unlikely that heparin/DHE is markedly superior to low dose heparin alone in this clinical setting.

Physician Preferences for Perioperative Anticoagulation in Patients With a Mechanical Heart Valve Who Are Undergoing Elective Noncardiac Surgery

Injuries increase the risk of venous thrombosis. So far, most research has focused on major injuries that are accompanied by other risk factors for venous thrombosis, such as plaster casts and surgery. We studied the association of venous thrombosis with common minor injuries, such as minor sural muscle ruptures and ankle sprains. We performed a large, population-based, case-control study (the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis [MEGA] study), including consecutive patients with a first deep venous thrombosis of the leg or pulmonary embolism and control subjects. Participants with malignant neoplasms, those who underwent surgery, and those who had a plaster cast or extended bed rest were excluded. Of 2471 patients, 289 (11.7%), and of 3534 controls, 154 (4.4%) had a minor injury in the 3 months preceding the venous thrombosis (patients) or completion of the questionnaire (controls). Venous thrombosis was associated with previous minor injury (odds ratio adjusted for sex and age, 3.1; 95% confidence interval, 2.5-3.8). The association was strongest for injuries that occurred in the 4 weeks before thrombosis and was not apparent before 10 weeks. Thrombosis was more strongly associated with minor injuries located in the leg (odds ratio adjusted for sex and age, 5.1; 95% confidence interval, 3.9-6.7), while those located in other body parts were not associated. A 50-fold increased risk was found in factor V Leiden carriers with a leg injury compared with noncarriers without injury (odds ratio, 49.7; 95% confidence interval, 6.8-362.7). Minor injuries in the leg are associated with greater risk of venous thrombosis. Because minor injuries are common, they could be major contributors to the occurrence of venous thrombosis.

New gene variants associated with venous thrombosis: a replication study in White and Black Americans

In a randomized study of 128 patients, we evaluated intermittent pneumatic compression of the calf in the prevention of leg scan-detected venous thrombosis in intracranial disease. Pneumatic compression of the calf for 5 days reduced the rate of venous thrombosis from 12 of 63 control patients (19.1 percent) to one of 65 patients (1.5 percent) given prophylaxis (p = 0.00082). In patients who had craniotomy for brain tumor, subarachnoid hemorrhage, or subdural hematomas, calf compression reduced the incidence of venous thrombosis from nine of 49 control patients (18.4 percent) to one of 53 patients (1.9 percent) given prophylaxis (p - 0.0051). In patients who remained at risk after 5 days, the rate of venous thrombosis was no different in the control group than in the group that had received prophylaxis.

The latest updates to the NCCN Guidelines for perioperative management of anticoagulation and antithrombotic therapies reflect significant changes in the use of bridging anticoagulation. For patients with low- to intermediate-risk atrial fibrillation, the standard of care has shifted toward reduced reliance on bridging anticoagulation. The rationale for this shift is based on the BRIDGE trial, which revealed a 3-fold greater risk of major bleeding without significant reduction in thrombotic outcomes in patients receiving bridging therapy. In patients with mechanical heart valves, findings from the PERIOP2 study led to similar conclusions. Both of these studies have contributed to a paradigm shift in perioperative anticoagulation management, pivoting toward personalized therapy based on patient-specific bleeding and thrombotic risks. For emergent or elective surgeries, the NCCN Guidelines provide a framework for more individualized decision-making, emphasizing the need for ongoing cooperation among physicians, surgeons, and patients.