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Tafur AJ, Barnes GD, Bhagirath VC, Douketis J. Anticoagulation Stewardship to Bridge the Implementation Gap in Perioperative Anticoagulation Management. TH OPEN 2024; 8:e114-e120. [PMID: 38476982 PMCID: PMC10927368 DOI: 10.1055/a-2259-0911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 12/18/2023] [Indexed: 03/14/2024] Open
Abstract
Lack of alignment of care protocols among providers in health care is a driver of increased costs and suboptimal patient outcomes. Perioperative anticoagulation management is a good example of a complex area where protocol creation is a clinical challenge that demands input from multiple experts. Questions regarding the need for anticoagulation interruptions are frequent. Yet, due to layers of complexity involving analysis of anticoagulation indication, surgical risk, and anesthesia-associated bleeding risk as well as institutional practices, there is heterogeneity in how these interruptions are approached. The recent perioperative anticoagulation guidelines from the American College of Chest Physicians summarize extensive evidence for the management of anticoagulant and antiplatelet medications in patients who undergo elective interventions. However, implementation of these guidelines by individual clinicians is highly varied and often does not follow the best available clinical evidence. Against this background, anticoagulation stewardship units, which exist to improve safety and quality monitoring for the anticoagulated patient, are of growing interest. These units provide a bridge for the implementation of value-based, high-quality guidelines for patients who need perioperative anticoagulation interruption. We use a case to pragmatically illustrate the problem and tactics for change management and implementation science that may facilitate the adoption of perioperative anticoagulation guidelines.
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Affiliation(s)
- Alfonso J. Tafur
- Department of Medicine, Vascular Medicine, NorthShore—Edward-Elmhurst Health, Evanston, Illinois, United States
- Department of Medicine-Cardiovascular Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
| | - Geoffrey D. Barnes
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | | | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Mogavero T. Regional anaesthesia in patients receiving antithrombotic therapy: low evidence and conservative views. Eur J Anaesthesiol 2023; 40:67-68. [PMID: 36479994 DOI: 10.1097/eja.0000000000001729] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Tindaro Mogavero
- From the Department of Anaesthesia and Intensive Care, Santa Chiara Hospital, APSS Trento, Largo Medaglie d'Oro 9, Trento, Italy (TM)
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Zhang Q, Ling M, Wang X, Cui D. A Comparison of Two Peripheral Nerve Blocks Combined With General Anesthesia in Elderly Patients Undergoing Arthroplasty for Hip Fractures: A Pilot Randomized Controlled Trial. Front Surg 2022; 9:715422. [PMID: 35252320 PMCID: PMC8891216 DOI: 10.3389/fsurg.2022.715422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Combined anesthesia can be a promising option for hip surgery when neuraxial anesthesia is contraindicated. Lumbar and sacral plexus blocks, and femoral nerve and lateral femoral cutaneous (LFC) nerve blocks in combination with general anesthesia (GA) are commonly used in elderly patients undergoing arthroplasty for hip fracture surgery. However, no study has compared these two anesthetic strategies in the perioperative period. Methods A total of 41 elderly patients scheduled for arthroplasty for hip fracture surgery were randomized into group A (n = 20) and group B (n = 21). Group A received femoral nerve block, LFC nerve blocks, and GA, and group B received lumbar plexus block, sacral plexus block, and GA. Primary outcomes were incidences of hemodynamic events and changes in blood pressure (BP) and heart rate (HR). Secondary outcomes included time and drug consumption, infusion and bleeding volume, eyes opening time after surgery, and postoperative quality recovery rate. Results Compared with group B, group A showed a lower incidence of intraoperative hypotension (p < 0.001), higher BP [including mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP)] following induction (IN), and higher HR from mid-surgery. Time required for nerve blockade (p < 0.001) and ephedrine consumption was significantly shorter in group A (p < 0.001), while sufentanil consumption was higher as compared to group B (p = 0.002). No significant differences in other intraoperative parameters and postoperative quality recovery rate were reported during the observation. Conclusion Our pilot data indicate that compared with lumbar and sacral plexus blocks, femoral nerve and LFC nerve blocks may provide more stable intraoperative hemodynamics and a comparable postoperative recovery for elderly patients undergoing arthroplasty for hip fracture under GA. Further studies with a larger sample size are needed to derive stronger evidence.
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Affiliation(s)
- Qingfu Zhang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ming Ling
- Department of Orthopedics, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Xintao Wang
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Derong Cui
- Department of Anesthesiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China
- *Correspondence: Derong Cui
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Chen AT, Patel M, Douketis JD. Perioperative management of antithrombotic therapy: a case-based narrative review. Intern Emerg Med 2022; 17:25-35. [PMID: 34652572 DOI: 10.1007/s11739-021-02866-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. In many minimal-bleed-risk procedures, anticoagulants can be safely continued, without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging requires consideration. Perioperative antithrombotic management scenarios occur most often in patients with atrial fibrillation, mechanical heart valves, coronary stents, and cerebrovascular disease as such patients are likely to be prescribed anticoagulant and/or antiplatelet therapy. The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.
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Affiliation(s)
- Andrew Tiger Chen
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - Matthew Patel
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada
| | - James Demetrios Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton, McMaster University, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada.
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