For many years, bridging with heparin was the usual approach for almost all patients having surgery. For patients undergoing neuraxial anesthesia, hold doac 72 hours prior to procedure. Anticoagulation protocol federal bureau of prisons. National patient safety goals effective january 2020. Bridging protocol, intermountain health care chronic anticoagulation clinic cac, revised nov. Pdf perioperative management of anticoagulant therapy. Perioperative bridging anticoagulation in patients with. Perioperative bridging anticoagulation in patients with atrial fibrillation thrombosis. Bridging anticoagulation protocol for management of anticoagulation in the perioperative period contd protocols standard anticoagulants i. Perioperative management of patients on direct oral. Guidelines on perioperative management of anticoagulant and.
Clinical practice guideline cpg development template uw health. Anticoagulation management american college of cardiology. The approach to the management of anticoagulation in patients with prosthetic valves undergoing noncardiac surgery remains controversial. Management of anticoagulation in the periprocedural. To provide an approach to the perioperative management of warfarin treated patients who require an elective or urgent surgeryprocedure. This protocol is designed to guide clinicians in fulfilling the following objectives. The elimination halflife of heparin is dose dependent and increases from approximately 30 min after a bolus of 25 ukg, to 60 min. All cleveland clinic licensed independent practitioners lips are expected to use this program if questions arise when prescribing mechanical devices, anticoagulation or thrombolytic. Perioperative management of antithrombotic therapy antithrombotic therapy and prevention of thrombosis, 9th ed.
Use the link below to share a fulltext version of this article with your friends and colleagues. Perioperative management of antithrombotic therapy chest. Clinical practice guideline for anticoagulation management. There is little evidence to guide the perioperative interruption of direct oral anticoagulants doacs. Perioperative interruption of direct oral anticoagulants in. The hospital uses approved protocols and evidencebased practice guidelines for reversal of anticoagulation and management of bleeding events related to each anticoagulant medication. If warfarin is used for anticoagulation, initiate it on. Perioperative management of patients on warfarin and the new oral anticoagulants emily hattonwyatt and jason pruchniewicz correspondence.
The perioperative management of antithrombotic therapy. Grigg, haematology department, royal melbourne hospital, melbourne synopsis the perioperative management of patients on longterm warfarin therapy poses particular problems. Perioperative warfarin management should be carefully. Isth 2015 thomas ortel, chief, division of hematology, professor of medicine and hematology. Intracranial, spine or posterior eye surgeryin patients with a history of stroke, admi, pad, venous or arterial thrombosis. Perioperative management of the chronically anticoagulated. New observational studies and a recent large randomized trial have noted signi. Perioperative management of patient who are receiving warfarin therapy. Each year, 1015% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. Perioperative management of oral anticoagulation victoria lambert, pharmd, cacp medication management pharmacist janki shah, pharmd, bcacp anticoagulation care provider william w. Patient risk factors congenital and acquired bleeding. Purpose the purpose of this bop anticoagulation protocol is to outline a recommended approach to therapeutic anticoagulation that minimizes the risk of both thromboembolic and bleeding events. Association task force on clinical practice guidelines an dthe heart. This situation is exacerbated by the absence of randomised trials.
Perioperative management of anticoagulation and antiplatelet therapy date. Oral anticoagulant warfarin guidelines oxford university hospitals. For example, cardiothoracic and vascular surgical units will. Updated guidelines on outpatient anticoagulation patricia wigle, pharmd, bcps, and bradley hein, pharmd. The simple rationale was that heparin would provide an antithrombotic effect. Perioperative anticoagulation management zukowski 2018. The perioperative management of anticoagulation rohini sridhar and andrew p. In north america, there are over one million people with mechanical prosthetic heart valves, chronic atrial fibrillation, or a history of venous thromboembolism, receiving longterm oral anticoagulation therapy with warfarin coumadin. Older people are both more likely to need anticoagulation and to require more surgeries or procedures than younger people. Aug 06, 2019 i read grants commentary on the use of perioperative bridging anticoagulation with interest 1. Assess inr at least 7 days before surgery or procedure to allow for planning of perioperative management. The perioperative management of patients who are receiving anticoagulant therapy is already a frequently encountered clinical scenario, likely to increase due to an ageing population. Perioperative management of warfarin coumadin uc san.
Follow the steps below to manage anticoagulation therapy in the perioperative setting. Perioperative anticoagulation is accompanied by an increased risk of postoperative bleeding. Simple dental procedures including extractions if there is coadministration of an oral prohemostatic agent. Moreover, indications for anticoagulation interruption may be unclear. Perioperative anticoagulation management in patients who.
The methods herein follow those discussed in the methodology for the development of antithrombotic. Omit warfarin for five days before the procedure last dose on preoperative day minus 6. Reorder heparin 12 hours after surgery if there is no. Antithrombotic therapy and prevention of thrombosis, 9th ed. Do the benefits of anticoagulation outweigh the risks. For those with active clot or high risk for clotting, there must be a five day overlap of both drugs.
To provide an approach for bridging anticoagulation, if needed, during warfarin interruption. I read grants commentary on the use of perioperative bridging anticoagulation with interest 1. The simple rationale was that heparin would provide an. This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure. Patients with atrial fibrillation af frequently undergo invasive procedures that require temporary interruption of anticoagulation. Mar 29, 2018 perioperative anticoagulation management. If pe is clinically likely, initiation of anticoagulation should not await testing. The cha2ds2vasc score has shown better discrimination of patients at truly low risk of thromboembolism te 30. Warfarin may be continued during procedures where bleed risk is low. Take inr 1 day prior ideally or the morning of the procedure urgently.
Reorder heparin 12 hours after surgery if there is no evidence of bleeding. Perioperative management of patients receiving anticoagulants. Guidelines on perioperative management of anticoagulant and antiplatelet agents page 4. Clinical excellence commission, 2018, guidelines on perioperative management of anticoagulant and. While the thromboembolic risk is determined by the patients condition, the perioperative management of doacs is vastly different and varied. This website contains uw medicine recommendations, guidelines and protocols for the treatment and prevention of venous and arterial thrombosis, and the clinical use of antithrombotic agents in ambulatory and inpatient settings uw medicine anticoagulation services is operated by the uw medicine department of pharmacy, and collaborates with multidisciplinary specialties and. Thrombosis the commonest cause of death and disability worldwide antithrombotic therapy is very beneficial antithrombotic therapy increases bleeding. It is a patients estimated thromboembolic risk that determines whether a conservative or aggressive periprocedural antithrom. Algorithm for managing anticoagulation perioperatively.
To provide an approach for bridging anticoagulation if needed during warfarin interruption. Here is parc preoperative medication guidelines author. Readers are advised to analyze and apply this information in their own practices. Courtney meredith zukowski pharmd, bcps, cpp, cacp. View the article pdf and any associated supplements and figures for a. The following information outlines the cleveland clinic anticoagulation management program also known as ccamp. July 31, 20 in general, the perioperative management of medications will most often require direct communication between surgery and anesthesiology often with input from cardiology or medicine. The thromboembolic risk of the patient chads2 or cha2ds2vasc score the chads2 score and the cha2ds2vasc score are used to predict afrelated thromboembolic risk in the absence of anticoagulation and to determine anticoagulant therapy 28, 29. Protocol this trial protocol has been provided by the authors to give readers additional information about their work. Anticoagulation management clinical topic collection gathers the latest guidelines, news, jacc articles, education, meetings and clinical images pertaining to its cardiovascular topical area all in one place for your convenience. Decisions about perioperative anticoagulation in this circumstance should be made by or referred to the admitting surgeon unless there are explicit local delegation arrangements in place. Adult heparin drip protocol ventura county, california.
In each individual patient, rational decisions must be made after weighing up the haemorrhagic and thrombotic risks. The methods herein follow those discussed in the methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines. Periprocedural or bridging anticoagulation administration of a short acting. Use of protocols and guidelines for anticoagulation reversal and management of bleeding events related to each anticoagulant medication establish a process to identify, respond to, and report adverse drug events use of protocols and guidelines for perioperative management of all patients on oral anticoagulants. Periprocedural and regional anesthesia management with. Canadian cardiovascular society guidelines on antiplatelet therapy, which discusses perioperative. The hospital uses approved protocols and evidencebased practice guidelines for perioperative management of all patients on oral anticoagulants.
Pdf about 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an. Management of anticoagulation in the periprocedural period mappp app. In patients undergoing a procedure which carries a high risk of bleeding, the perioperative anticoagulation depends on a. The following changes have been made to the bop anticoagulation protocol since it. Hospital national patient safety goals on anticoagulation 2019. Guidelines for prescribing, monitoring and management oral anticoagulants guideline for prescribing, monitoring and management v3 author. Practice advisories and guidelines represent the opinions of the respective authors. Perioperative management of antiplatelet therapy in patients undergoing noncardiac procedures may 2016. Federal bureau of prisons anticoagulation protocol clinical guidance march 2018 4 1. Perioperative bridging anticoagulation annals of internal.
Backus hospital faculty disclosures there are no actual or potential conflicts of interest associated with this presentation. If only dvt is suspected and testing will be prompt, initiation of anticoagulation may await testing. The perioperative management of anticoagulation australian. The perioperative management of patients who receive a direct oral anticoagulant doac for atrial fibrillation af and require elective surgery or procedure is a common clinical scenario for which best practices are uncertain. The purpose of this bop anticoagulation protocol is to outline a recommended approach to therapeutic anticoagulation that minimizes the risk of both thromboembolic and bleeding events. Perioperative management of cardiovascular medications. Direct oral anticoagulants doacs have been licensed worldwide for several years for various indications. American college of surgeons guidelines for the perioperative. Currently there is no evidence to suggest a benefit from the use of heparin bridging in patients taking doacs. Perioperative management of patients on oral anticoagulants guideline. These decisions should not be made by junior medical officers. Warfarin bleeding cardiology and surgeon should collaborate to. Procedure bleeding risks1 interventional radiology 1 for patients on antiplatelet therapy, see management of antiplatelet therapy in patients with cardiac stents undergoing procedures algorithm note.
Overview, instructions and case studies may 12, 2017. Anticoagulation is not advisable if the risk of harm is likely to outweigh the benefits of treatment. The perioperative guidelines have undergone numerous. In a cohort study of 541 patients receiving dabigatran who had standardized perioperative interruption and resumption of their treatment, the 30day postoperative rate of major bleeding was 1. Consider prophylactic dose dalteparin postoperatively as per mtw vte prevention guidelines 2. Perioperative management of anticoagulation and antiplatelet. Argatroban and bivalirudin for perioperative anticoagulation.
The guidelines cover the assessment of perioperative thromboembolic risk secondary to the medical condition, the strati. American college of chest physicians evidencebased clinical practice guidelines 8th edition. Therapeutic levels of anticoagulation should be achieved as quickly as possible. There is no consensus on the optimal approach to anticoagulation in the perioperative period. Nonvitamin k antagonist oral anticoagulants noac guidelines page 2 clinical excellence commission updated july 2017 the cec acknowledges the nsw health directors of clinical governance who commissioned this guideline and. American college of chest physicians evidencebased clinical practice guidelines article of this supplement. Slow intravenous injection of protamine 1% solution. Recommence usual warfarin dose on evening of surgery if no. The proforma should contain calendar outlining the perioperative timing of. Warfarin perioperative management thrombosis canada. Unfractionated heparin ufh is the mainstay of anticoagulation for cardiovascular surgery, for patients requiring extracorporeal membrane oxygenation ecmo, initially for ventricular assist devices vads, and for postoperative thrombosis prophylaxis. Table 2 shows items to consider in a perioperative checklist. Updated guidelines on outpatient anticoagulation patricia wigle, pharmd. Regional anesthesia in the patient receiving antithrombotic.
Venous venous thromboembolism vte michigan medicine. In the absence of a universally accepted definition, 6 x 6 douketis, jd, berger, pb, dunn, as. Perioperative management of patients with atrial fibrillation. Management of anticoagulation in the periprocedural period. Periprocedural management of anticoagulation is a common clinical conundrum that involves a multidisciplinary team, cuts across many specialties, and varies greatly between institutions in the way it is practiced.
978 220 1341 323 1400 34 1136 1552 1598 789 194 1365 638 1184 560 996 492 1047 388 716 792 1318 746 692 201 1189 791 796 432 1019 698