What is Perioperative Anticoagulation Management?
Doctors face a daily challenge when managing patients who are on blood thinning and clot prevention medications. Stopping these medications can increase the risk of blood clots during and after surgery. But, if these medications are not stopped, it can increase the risk of bleeding during surgery, and this can lead to outcomes ranging from minor to severe uncontrolled bleeding.
The best way to manage these patients is to balance the risk of blood clots and bleeding. Many factors can influence the decision to stop or continue these medications before surgery. These factors include the patient’s existing risk of bleeding, the risk of bleeding related to the surgical procedure, when to stop and start the blood thinning medication again, and whether to use a temporary alternative medication. These are all common questions that will be discussed in this review.
What Causes Perioperative Anticoagulation Management?
Anticoagulants, also known as “blood thinners,” are medications often used to treat conditions that may cause blood clots. These conditions include irregular heartbeat (atrial fibrillation), a blood clot in your veins (deep vein thrombosis), a blood clot in your lungs (pulmonary embolism), and after getting artificial heart valves. People who have had a procedure to improve blood flow to the heart (percutaneous coronary intervention) usually take two types of blood thinners.
Patients with a history of stroke, a heart bypass operation (coronary artery bypass grafting), or a disorder causing too many platelets in the blood (essential thrombocytosis) might also need blood thinners. This medication helps in preventing future complications related to clots.
Risk Factors and Frequency for Perioperative Anticoagulation Management
Atrial fibrillation (AF), deep vein thrombosis (DVT), and pulmonary embolism (PE) are the main reasons why people need anticoagulation treatment. In the United States alone, between 3 to 5 million people are living with atrial fibrillation. This number is predicted to rise to 8 million by 2050. Additionally, every year, around 250,000 patients need to stop their anticoagulation therapy so they can be prepared for surgeries.
- AF, DVT, and PE are the primary reasons for anticoagulation treatment.
- In the United States, 3 to 5 million people have atrial fibrillation.
- Projections suggest this number could increase to 8 million by 2050.
- Each year, about 250,000 patients in the U.S. need to pause their anticoagulation therapy for surgeries.
Testing for Perioperative Anticoagulation Management
When you’re having an elective surgery, doctors consider four main things to make sure the process goes smoothly and safely.
Firstly, they’ll look at your risk of developing blood clots. Conditions like irregular heartbeat, prosthetic heart valves, and a recent clot can increase this risk. Doctors often use a scoring system to predict this risk. They will also consider how precisely the valve was placed, how many replacement valves you have, and any other related risks. With blood clots, the time since the last episode and the risk of another one happening will be considered when deciding the risk level. Blood clots can be more likely to repeat if there was a clear reason for them – for instance if you have particular medical conditions or inherited traits that make blood clots more likely.
Secondly, doctors will consider how likely you are to experience bleeding during or after surgery. This is assessed using a scoring system that takes into account your blood pressure, liver and kidney function, stroke history, bleeding history, tendency to bleed, stability of blood clotting time, age, and drug and alcohol use. Each factor gives 1 point, and a score higher than 3 means a high risk of bleeding during or after surgery. Certain types of surgeries carry more risk of major bleeding than others.
The third consideration is whether to stop blood thinning medication. Stopping these medications could lower bleeding risk, but may increase the risk of developing a blood clot. This risk and benefit trade-off should be carefully considered and decisions should be individualized.
Finally, your doctor will determine if you need bridging therapy. Bridging therapy is a strategy used to maintain a lower risk of blood clots when long-acting blood thinners (usually warfarin) are temporarily stopped. This is achieved by switching you to a medication that is fast-acting and leaves the system quickly (usually a type of heparin) for a short period. This is only beneficial for patients at high risk of blood clots. Again, your doctor will weigh the potential benefits and risks based on your individual health profile. Remember, good communication with your healthcare team is critical when planning for a surgery. Always ask questions if you don’t understand something, and share all your medical history and medication details to help them make the best decision for you.
Treatment Options for Perioperative Anticoagulation Management
Recommended guidelines for managing blood-thinning medications before surgery suggest stopping warfarin five days prior to the procedure, and possibly starting a different type of blood thinner three days before surgery. If a patient’s blood is too thin two days before surgery, vitamin K may be used to counteract this. When possible, blood thinners are usually discontinued 24 hours before surgery.
In the phase after surgery, blood-thinning medicine like warfarin is generally restarted 12 to 24 hours after the procedure, as long as the patient can eat and drink normally and there are no unexpected issues that might increase the risk of bleeding. If a patient was previously on a different type of blood thinner before surgery and had a minor operation, that medicine may be resumed 24 hours after the operation. If the surgery was major, that medicine may be resumed between 48 to 72 hours after the operation. The specific timing will depend on the risk of bleeding and how well the body’s natural mechanism for stopping blood loss (hemostasis) is working.
Patients on a certain class of blood thinners known as DOACs do not require bridging therapy. These medicines can be safely discontinued for a certain period of time before surgery based on different factors, including the type of surgery and the patient’s overall health and kidney function.
Patients who have had a recent coronary stent implant are usually advised not to have elective surgery until 6 weeks after the stent for a bare metal type, or 6 months after for a drug-eluting type. If surgery cannot wait, it is ideal to continue taking two kinds of blood-thinning medicines throughout the entire operation period. For non-emergency situations in high-risk heart patients, aspirin is usually continued, clopidogrel and prasugrel are stopped 5 days before surgery, and then resumed 24 hours after the operation. In low-risk heart patients, it might be possible to stop dual antiplatelet therapy 7 to 10 days before surgery and restart it 24 hours after.
For patients undergoing spinal anesthesia, the recommendations defer based on the type and dose of the blood-thinning medicine. Once again, the timing for discontinuation and resumption is important, and any risks will be considered by your doctor.
In the case of an urgent surgery, the timescale for managing the blood thinners can vary, but usually there’s a need to reverse the blood thinning effect quickly. This can be done using different kind of drugs, including vitamin K, ‘prothrombin complex concentrate’ or fresh frozen plasma. In extreme cases, a new drug called ‘andexanet alfa’ has been approved for rapidly reversing the effects of certain types of blood thinners.
What else can Perioperative Anticoagulation Management be?
While there are numerous possible causes of unexplained bleeding, some of the potential causes could include:
- Acute Anemia (a condition where your blood lacks enough red blood cells or hemoglobin)
- Afibrinogenemia (a very rare blood clotting disorder)
- Child abuse (which may lead to physical injuries)
- Dysfibrinogenemia (a disorder that affects blood clotting)
- Epistaxis (also known as nosebleeds)
- Factor V deficiency (a rare blood clotting disorder)
- Factor X deficiency (another condition impacting blood clotting)
- GI bleeding (bleeding that occurs in the gastrointestinal tract)
- Idiopathic Thrombocytopenic Purpura (a disorder that can lead to excessive bruising and bleeding)
- Liver failure (can cause blood clotting issues due to reduced production of proteins needed for blood clotting)
- Munchausen syndrome (a mental disorder in which a person repeatedly acts as if they have a physical or mental illness when they are not really sick)
- Subdural hematoma (a bleed on the surface of the brain)
- Type A haemophilia (the most common type of haemophilia, a blood clotting disorder)
- Type B haemophilia (also known as Christmas disease, another type of haemophilia)
Possible Complications When Diagnosed with Perioperative Anticoagulation Management
Incorrect timing of stopping anticoagulation medication before surgery can lead to two major problems. The first is bleeding, which can happen when anticoagulation therapy is not stopped appropriately before surgery. On the other hand, if these medications are stopped too soon, patients can be at a high risk for developing blood clots. This is because surgeries can naturally lead to a state where the blood is prone to clotting. So, properly managing when to stop anticoagulation therapy during the time around an operation is a careful balancing act. Doctors need to be extra careful to avoid the possible serious complications of bleeding and blood clots.
Possible Complications:
- Bleeding from not stopping anticoagulation medication timely
- High risk for blood clots from stopping medications too soon
