Anticoagulation and elective surgery

Postoperative Complications of Hip Fractures Patients on Chronic Coumadin: A Comparison Based on Operative International Normalized Ratio

In current clinical practice, orthopedic surgeons often delay the surgery intervention on geriatric hip fracture patients to optimize the international normalized ratio (INR), in order to decrease the risk of postoperative hematological complications. However, some evidence suggests that full reversal protocols may not be necessary, especially for patients with prior thromboembolic history. Our study aims to compare the surgical outcomes of patients with normal versus elevated INR values. We conducted a retrospective chart review on 217 patients who underwent surgeries on hip fractures at two academic trauma centers. We found that in our group (n = 124) of patients with an INR value of 1.5–3.0, there was only one reoperation for a hematoma, but there was a trend for more blood transfusions. There was no statistically significant difference in the odds of reoperation or overall complications. Nevertheless, there were significantly more events of postoperative anemia in this high INR patient group.

Changing trends in epidemiology and management of facial trauma in a Swiss geriatric population

OBJECTIVE

To assess the prevalence and surgical treatment of facial fractures in a Swiss population aged 65 and over.

BACKGROUND

The knowledge of the characteristics of geriatric trauma may help to prevent injuries and better allocate clinical resources for the management of multimorbid patients.

MATERIAL AND METHODS

This study retrospectively evaluated a cohort of 181 patients who presented at the Bern University Hospital in Switzerland from May 2012 to September 2016. Data on age, gender, aetiology and type of trauma, treatment and complications, co-morbidities and associated injuries were obtained.

RESULTS

Women were most frequently affected (55.2%). Mean age was 80 years. Zygomatic complex fractures were the most frequent type of fractures (37%), followed by isolated orbital fractures (27.6%). Falls were the most common cause of trauma (76.1%). Thirty-five per cent of all patients were taking anticoagulation or platelet aggregation medication. Hospitalisation was required in 88.4%, whereby 92.3% of the patients underwent surgical treatment. Surgery had to be performed immediately in three cases to treat compression of the optic nerve. Median hospital length of stay was 4 days, with 68% of patients returning to a domestic environment and 32% being transferred to another institution for further treatment.

CONCLUSION

The most common cause of facial injuries is a fall while standing in a domestic environment. Midface fractures were the most common type of fractures.

Management of patients on long-term oral anticoagulant therapy undergoing elective surgery: survey of the clinical practice in the Italian anticoagulation clinics

In the perioperative management of patients on long-term oral anticoagulant (OAC) therapy the problem is balancing the thromboembolic (TER) and the haemorrhagic risk (HR) in the perioperative period. The Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) activated an online registry from November 2001 to August 2003 in order to collect information on the management of these patients in Italy. Four hundred and eleven patients, undergoing elective major (18%) and minor surgery (82%), from 7 centres, were registered. Three hundred and ninety-nine out of 411 patients received LMWH either once a day (310 patients) or twice a day (89 patients) during OAC therapy discontinuation. Two thromboembolic (0.48%) and 16 bleeding events (7 major; 1.7%) were reported. Notwithstanding the lower doses of heparin (54.3 U/kg o.d. and 64.4 U/kg b.i.d.), the thromboembolic complications are in line with those reported in the literature. The data of this study suggest that the intervention with LMWH may be relevant only in the high-risk patients as already proposed by others.

A study of the safety of continued anticoagulation for cataract surgery patients

Cataract surgery is the most common procedure performed on Medicare recipients. Many of these patients have been on anticoagulation therapy (ACT) regimens, but no consistent standard currently governs the use or cessation of ACT prior to surgery. This study evaluated the safety of continuing ACT in cataract surgery patients (of ASA III physical status) at seven centers. There was a 53% incidence of previous ACT among the 1,842 individuals sampled. During 2,241 procedures, only two patients (one on ACT) experienced abnormal surgical bleeding, noted as hyphemas. Seventeen (0.9%), nine on ACT and eight not on it, had some type of bleeding related to regional anesthesia; of these, nine had bruising and eight had subconjunctival hemorrhage. No major complications were noted in the ACT group during surgery, or at visits 1 day and 1 week postoperatively.

Outpatient management of the chronically anticoagulated patient for elective surgery

With the appropriate use of preadmission clinics, "hospital in the home" programs, and alternatives to intravenous heparin, the majority of chronically anticoagulated patients can be managed as outpatients prior to elective surgery. The preoperative management depends on the original indication for long-term anticoagulation, the interval since the last thromboembolic event, and the extent and type of surgery planned. Only patients who are undergoing major surgery, and who have a high risk of recurrent thrombosis or embolism, require preoperative admission to hospital and conversion to an intravenous heparin regimen. Patients undergoing minor surgery may require no change to their oral anticoagulation. The remainder require cessation of oral anticoagulation and alternative thromboprophylaxis preoperatively, which can be achieved on an outpatient basis using low molecular weight heparin. Outpatient anticoagulation management requires a clear protocol that is understood and agreed to by all parties involved in the care of surgical patients perioperatively.

Dalteparin as periprocedure anticoagulation for patients on warfarin and at high risk of thrombosis

BACKGROUND

Patients taking warfarin and at high risk for thromboembolic complications have traditionally been hospitalized for two to three days to receive standard treatment with intravenous heparin both prior to and following procedures while their international normalized ratio (INR) is subtherapeutic.

OBJECTIVE

To assess the feasibility of protocol implementation for outpatient anticoagulation with low-molecular-weight heparin to eliminate or reduce the length of hospital admission needed solely for anticoagulation.

METHODS

Patients included were receiving warfarin for a prosthetic heart valve, mitral valve disease with atrial fibrillation, or recent episode of venous thromboembolism. Warfarin was discontinued four days prior to the procedure. Subcutaneous dalteparin 200 units/kg was given on the two mornings prior to the procedure and restarted 12-24 hours after the procedure until the INR was in the therapeutic range. Warfarin was reinitiated on the evening of surgery.

RESULTS

Twenty-four patients underwent 26 procedures. There were two minor bleeding complications, and one patient experienced a transient ischemic attack. Patients received a median of five days of dalteparin. The INR returned to the therapeutic range on the median postoperative day 4. All patients avoided two days of hospitalization prior to the procedure (i.e., no patients needed to be admitted preoperatively for anticoagulation). A median of four days would have been required for the sole purpose of postoperative anticoagulation.

CONCLUSIONS

Outpatient perioperative anticoagulation with dalteparin for high-risk patients requiring long-term oral anticoagulation appears feasible and warrants further study.

Perioperative Anticoagulation Practices of Surgeons in a Health System

Several different management strategies for patients receiving long-term warfarin therapy who require surgery have been recommended in the literature. A recent article by Kearon and Hirsch made new recommendations based on estimating the risk of thromboembolism and bleeding from randomized trials and prospective studies. Because of the potential for variability in practice patterns, we surveyed physicians in our health system to identify their perioperative anticoagulation practices. Our results confirm variability in practice patterns. Perioperative intravenous heparin was the most frequently reported method of prophylaxis. Fifty-three percent of the surveyed physicians admitted patients to the hospital two or more days prior to surgery to receive prophylaxis. Further research is necessary to determine optimal management of perioperative anticoagulation.

Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations

There is wide variation in the management of patients with mechanical prosthetic valves who are taking anticoagulants and who require non-cardiac surgery. In this paper, we outline a pragmatic, practical approach to the adjustment of anticoagulation in relation to both the degrees of surgical trauma during oral and maxillofacial surgery and the risk of thromboembolism associated with the prosthetic valve. For minor surgery, no adjustment of anticoagulation is undertaken if the International Normalized Ratio is less than 4.0, if local haemostatic methods and tranexamic acid mouthwashes are used. For major surgery, warfarin is stopped preoperatively and low-molecular-weight heparin is used. For emergency surgery, partial reversal of anticoagulation with low-dose parenteral vitamin K is obtained.

Current Clinical Concepts in Perioperative Anticoagulation

Management of patients with significant risks for thromboembolism in the perioperative period requires consideration of both risks of thromboembolism and risks of anticoagulant therapy. Patients who are receiving warfarin therapy because of recent venous thromboembolism, nonvalvular atrial fibrillation, and mechanical heart valves are at increased risk during the interval when the warfarin is discontinued and when the international normalized ratio is at a subtherapeutic level. In patients with an acute venous thromboembolic event within the past month, the use of intravenous heparin appears to be justified both preoperatively and postoperatively. If the venous thromboembolic event was within the past 2 to 3 months, use of intravenous heparin appears justified in the postoperative period. More than 3 months after an acute episode of venous thrombophlebitis, the relatively low risk of recurrence does not appear to justify the risks of complications from intravenous heparin. Patients with increased risks of arterial embolism, specifically those with nonvalvular atrial fibrillation and mechanical heart valves, are generally not at sufficient risk of arterial embolism to justify use of intravenous heparin during the perioperative subtherapeutic international normalized ratio interval when warfarin is withheld. A potential increased risk of recurrent arterial embolism when the preceding event was within a month suggests that elective surgery should be deferred beyond a month whenever possible in such patients. The use of fixed-dose, subcutaneous low molecular weight heparin has been observed to have advantages over use of unfractionated intravenous heparin both in terms of safety and efficiency. Further refinements in management of patients with significant risks of thromboembolism may occur with increased experience with low molecular weight heparin.