Stopping anticogulation before surgery and bridging

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Why this page is important: Bridging is the use of a short-acting parenteral agent to reduce the interval without anticoagulation However, this needs to be balanced with the importance of mitigating the risk of postoperative bleeding
 Drug Stopping before surgery Resuming after surgery Bridging

Apixaban& Edoxaban &Rivaroxaban

High bleeding risk procedure

  • Omit 3 days before a procedure
  • ie skip doses of rivaroxaban on surgical days, minus 2, minus 1 and the day of surgery

Low bleeding risk procedure

  • Omit 2 days before procedure 
  • ie skip doses of rivaroxaban on surgical days, minus 1 and the day of surgery

High bleeding risk procedure

  • Restart at the same dose the patient was receiving preoperative 2-3 days after surgery, and if needed use prophylactic dose LMW heparin for this period.
  • Since DOACs have a rapid onset of action, caution should be used in patients who have had major surgery or other procedures associated with a high bleeding risk. 

Low bleeding risk procedure

  • Restart at the same dose the patient was receiving preoperative 1 day after surgery

 

 

In general, the rapid offset and onset of DOACs obviates the need for bridging anticoagulation.

In rare cases, bridging may be required, such as the use of postoperative bridging in individuals who have a very high thromboembolic risk and are unable to take oral medications postoperatively due to intestinal ileus from gastrointestinal surgery.

 The haematologist will be able to advise as to whether high risk patients may need bridging therapy with a parenteral anticoagulant 

Dabigatran

Check serum creatinine several days prior to elective surgery

    • if CrCL > 80 stop 2 days if high risk bleeding and 24 hours before if low risk bleeding
    • if CrCL is 50-80 stop 2-3 days if high risk bleeding and 1-2 days before if low risk bleeding
    • if CrCL is 30-50 stop 4 days f high risk bleeding and 2-3 days before if low risk bleeding
  • If acute surgery is required, the surgery or intervention should be delayed if possible for at least 12 hrs after the last dose
  • When rapid reversal of the anticoagulation effect is required the specific reversal agen (Praxbind® , idarucizumab) to Pradaxa is available

In the post-procedural period, Dabigatran treatment can be re-instated as soon as clinically indicated 

Dabigatran should be resumed postoperatively when hemostasis has been achieved, at the same dose the patient was receiving preoperatively. Since dabigatran has a rapid onset of action, with peak effects occurring two to three hours after intake, caution should be used in patients who have had major surgery or other procedures associated with a high bleeding risk.

 

We often delay resumption of dabigatran for two to three days after high bleeding risk procedures and, if needed, administer a lower dabigatran dose for the initial two to three postoperative days (eg, 110 mg once daily) or use prophylactic dose LMW heparin for this period. We generally restart dabigatran one day after low bleeding risk surgery (if it was interrupted) and two to three days after high bleeding risk surgery.

In general, the rapid offset and onset of dabigatran activity obviates the need for bridging anticoagulation.

We reserve bridging anticoagulation for selected individuals who are at very high risk for postoperative thromboembolism and require extended interruption of dabigatran.

Examples include postoperative bridging in patients who are unable to take oral medications postoperatively due to intestinal ileus from gastrointestinal surgery.

The haematologist will be able to advise as to whether high risk patients may need bridging therapy with a parenteral anticoagulant

Warfarin
  • Omit for five days before elective surgery (ie, the last dose of warfarin is given on day minus 6)
  • Check the PT/INR on the day before surgery
    • If the INR is >1.5, administer low dose oral vitamin K (eg, 1 to 2 mg) to hasten normalization of the INR and recheck the following day
    • Proceed with surgery when the INR is ≤1.4
    • An INR in the normal range is especially important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used. 
 We resume warfarin 12 to 24 hours after surgery, typically the evening of the day of surgery or the evening of the day after surgery, assuming there were no unexpected surgical issues that would increase bleeding risk and the patient is taking adequate oral fluids [8]. We use the same dose the patient was receiving preoperatively.  

High bleeding risk procedure

  • Avoid all heparin after surgery  Give prophylactic dose LMWH or UFH after surgery once haemostasis has been secured  Give therapeutic dose LMWH or UFH no sooner than 48 hours if haemostasis is secured i.e. therapeutic dose LMWH or UFH must not be given for at least 48 hours after high bleeding risk surgery. Instruction for the provision of post-operative heparin is the responsibility of the operating surgeon. Warfarin can be resumed, at the normal maintenance dose, the evening of surgery or the next day if there is adequate haemostasis, following discussion with the operating surgeon.

Bridging 

  • Bridging is the use of a short-acting parenteral agent to reduce the interval without anticoagulation, however, this needs to be balanced with the importance of mitigating the risk of postoperative bleeding. Therefore, it is reserved for individuals with a
    • chronically elevated thromboembolic risk
    • recent stroke
    • mechanical heart valve
    • CHA2DS2-VASc score >5
  • To minimize the period when anticoagulation is not being used
  • if there is a prolonged period during which the patient cannot take oral medications 
  • Cons: Increases bleeding risk without reducing the rate of thromboembolism
  • Once a decision to use bridging has been made, the next decision is whether to use bridging before the procedure, after the procedure, or both 
  • Bridging agent is started three days before surgery

 

 We generally initiate heparin bridging three days before a planned procedure (ie, two days after stopping warfarin), when the PT/INR has started to drop below the therapeutic range.

LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours. If a twice-daily LMW heparin regimen is given, the evening dose the night before surgery is omitted, whereas if a once-daily regimen is given (eg, dalteparin 200 international units/kg), one-half of the total daily dose is given on the morning of the day before surgery. This ensures that no significant residual anticoagulant will be present at the time of surgery, based on studies that have shown a residual anticoagulant effect at 24 hours after stopping therapeutic-dose LMW heparin

 

Unfractionated heparin – For therapeutic dose unfractionated heparin, we continue the intravenous infusion until four to five hours before the procedure, based on the biologic half-life of intravenous unfractionated heparin of approximately 45 minutes. If subcutaneous unfractionated heparin is used, typically with a dose of approximately 250 international units/kg twice daily, the last dose can be given the evening before the procedure.

 

Postoperative timing of bridging — Postoperative resumption of unfractionated heparin and LMW heparin is similar, based on the onset of anticoagulation at approximately one hour after administration for both forms of heparin, and peak anticoagulant activity at approximately three to five hours.

●The resumption of bridging, especially when given as a therapeutic-dose regimen, should be delayed until there is adequate hemostasis based on a clinical assessment of the wound site, drainage fluid amount, and expected postoperative bleeding; coupled, where appropriate, with hemoglobin levels [72]. This assessment will vary depending on the surgery type and individual patient considerations, and it may be difficult for surgery where ongoing bleeding is not readily apparent (eg, cardiac, intracranial).

 

●For those undergoing major surgery or those with a high bleeding risk procedure, therapeutic-dose unfractionated heparin or LMW heparin should be delayed for 48 to 72 hours after hemostasis has been secured [8].

 

●For most minor procedures associated with a low bleeding risk in which bridging is used (eg, laparoscopic hernia repair), therapeutic-dose unfractionated heparin or LMW heparin can usually be resumed 24 hours after the procedure.

 

Resumption of bridging anticoagulation too early, especially the use of therapeutic dose heparin within 24 hours after surgery, is associated with a two- to fourfold increased risk for major bleeding compared with no bridging or prophylactic dose heparin. The increased bleeding risk was demonstrated in the Prospective peri-operative enoxaparin cohort trial (PROSPECT), which evaluated bleeding risk in a cohort of 260 patients undergoing major surgery whose treating physicians used bridging anticoagulation [73]. In this trial, nine patients had major postoperative bleeding (3.5 percent), most on postoperative day 0, and 19 (7.3 percent) had minor bleeding.

Postoperatively, warfarin is generally resumed on the same postoperative day as the heparin. Heparin can be discontinued when the INR reaches the therapeutic range for individuals at moderate thromboembolism risk.

Individuals with heparin-induced thrombocytopenia — Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition in which heparin-induced antibodies to platelets can cause thrombocytopenia and/or venous or arterial thrombosis. (See "Clinical presentation and diagnosis of heparin-induced thrombocytopenia".)

Patients with HIT should not receive any heparin (eg, they should not receive heparin flushes, unfractionated heparin, or LMW heparin). Non-heparin anticoagulants that can be used in patients with HIT are discussed separately. (See "Management of heparin-induced thrombocytopenia"

 

 

Bridging anticoagulation involves the administration of a short-acting anticoagulant, typically a low molecular weight (LMW) heparin, during the interruption of a longer-acting agent, typically warfarin. The intent is to minimize the risk of perioperative thromboembolism.

 

For selected patients on warfarin (eg, mechanical mitral valve; stroke, systemic embolism, or transient ischemic attack within the previous 12 weeks; mechanical aortic valve and additional stroke risk factors; atrial fibrillation and very high risk of stroke [eg, CHADS2 score of 5 or 6]; venous thromboembolism within the previous 12 weeks; recent coronary stenting; previous thromboembolism during interruption of chronic anticoagulation), we suggest the use of bridging (Grade 2C).

 

For most other patients on warfarin with atrial fibrillation or VTE, we suggest not using bridging (Grade 2B). We feel more strongly about avoiding bridging the lower the baseline thromboembolic risk and the higher the bleeding risk.

 

In contrast to individuals on warfarin, bridging usually is not required for individuals receiving a direct thrombin inhibitor or factor Xa inhibitor, because these agents have shorter half-lives (table 2). (See 'Appropriate settings for bridging' above.)

 

Agent – When bridging is used, we prefer LMW heparin for most patients. An exception is an individual with renal insufficiency and/or hemodialysis requirement, for whom intravenous or subcutaneous unfractionated heparin can be used more easily. We do not use dabigatran, rivaroxaban, apixaban, or edoxaban for bridging. Non-heparin anticoagulants that can be used in patients with heparin-induced thrombocytopenia are discussed separately. (See 'Heparin product and dose' above.)

 

Timing – Bridging can be used preoperatively, postoperatively, or both, depending on the underlying condition for which the patient is being anticoagulated (table 9). The timing depends on the heparin product used and the procedural bleeding risk. Importantly, resumption of bridging anticoagulation too early is associated with an increased risk for major bleeding. (See 'When to bridge: Preoperative, postoperative, or both' above and 'Timing of bridging' above.)

 

Heart valve – Perioperative anticoagulation in individuals with prosthetic heart valves is presented separately. (See "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Management of antithrombotic therapy for invasive procedures'.)

 

Urgent/Emergency procedure – Reversal of the patient's usual anticoagulant may be required for more urgent or emergency procedures, or to treat perioperative bleeding. Agents with a potential prothrombotic effect (eg, immediate reversal agents, prothrombin complex concentrates, plasma products) should be reserved for the treatment of life-threatening, severe bleeding or anticipated severe bleeding (eg, intracranial hemorrhage, emergency major surgery with elevated prothrombin time/international normalized ratio [PT/INR]). (See 'Urgent/emergency invasive procedure' above and "Management of bleeding in patients receiving direct oral anticoagulants".)

 

  

Short course DOAC following elective hip/knee surgery

  • Elective hip replacement 
    • low molecular weight heparin (LMWH) for 10 days followed by
      • aspirin (75 mg or 150 mg) for a further 28 days OR
      • LMWH for 28 days combined with anti-embolism stockings until discharge from hospital OR
      • rivaroxaban (in preference to other DOACs)
  • Elective knee replacement 
    • aspirin (75 mg or 150 mg) for 14 days OR
    • LMWH for 14 days combined with anti-embolism stockings until discharge from hospital OR
    • rivaroxaban
  • Considering apixaban or dabigatran if none of the other suitable

 Reversal 

If semi-urgent reversal of warfarin is required (eg, within one to two days), warfarin should be withheld and vitamin K administered (eg, 2.5 to 5.0 mg of oral or intravenous vitamin K). (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Urgent surgery/procedure'.)

 

•If immediate reversal is required (eg, for emergency surgery or active bleeding), this can be achieved via the use of prothrombin complex concentrates (PCCs) or plasma products (eg, Fresh Frozen Plasma [FFP]; Plasma Frozen Within 24 Hours After Phlebotomy [PF24]) along with vitamin K (table 11) [74,75]. The 4-factor PCCs contain adequate amounts of all vitamin K-dependent clotting factors, whereas 3-factor PCCs may require supplementation with FFP for adequate factor VII (table 12). Of note, there is a thrombotic risk associated with these products, and they should be used only if there is life-threatening bleeding and prolongation of the INR by a vitamin K antagonist [75]. (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Serious/life-threatening bleeding'.)

 

Dabigatran – Dabigatran is an oral direct thrombin inhibitor; it can be reversed by idarucizumab (table 13). In an open-label study involving 503 patients who had bleeding or required emergency surgery, idarucizumab effectively reversed the anticoagulant effect of dabigatran [76]. The use of this agent as well as other potential strategies for individuals receiving dabigatran who are at great risk of serious bleeding with an emergency procedure are presented separately. (See "Management of bleeding in patients receiving direct oral anticoagulants".)

 

Rivaroxabanapixaban, and edoxaban – Rivaroxaban, apixaban, and edoxaban are oral direct factor Xa inhibitors; these anticoagulants can be reversed by andexanet alfa, approved in May of 2018. PCCs have been used in cases of potentially life-threatening bleeding, but this is not based on high-quality evidence (table 13). These and other potential strategies for individuals receiving these agents who are at great risk of serious bleeding with an urgent/emergency procedure are presented separately. (See "Management of bleeding in patients receiving direct oral anticoagulants".)

 

Algorithms for anticoagulant reversal depending on the severity of bleeding are provided by various societies and groups such as Thrombosis Canada.

Additional discussions of postoperative bleeding are presented separately. (See "Postoperative complications among patients undergoing cardiac surgery", section on 'Hematologic dysfunction'.)

https://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants#H3

apixaban dabigatran edoxaban rivaroxaban Warfarin heparin aspirin

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