Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach

A Quality Improvement Project to Assess if Preoperative Trauma Patients Are Receiving Their Prescribed Medications Preoperatively

Introduction All preoperative trauma patients should receive their preoperative medications regardless of being nil per os (NPO). Anticoagulants, angiotensin-converting enzyme inhibitors (ACE-I), and angiotensin II receptor blockers (ARBs) should be omitted. This is according to both local and national guidelines. We noticed that some preoperative patients have not been receiving their morning medications prior to having their operations. This has led to pre and perioperative complications. The aim of this study, therefore, was to conduct a quality improvement project to assess if preoperative trauma patients are receiving their prescribed medications preoperatively when placed NPO. We then aimed to determine the adverse outcome associated with omission and to furthermore devise a robust system to prevent recurrence. Methods Data were collected from the relevant patients' drug charts on the day of the operation. These cases were available on the daily trauma list. We evaluated if there was any clear reason documented for not providing the medications. Following the first round, we implemented our action plan for posters to be taped to drug trolleys on the orthopedic wards and informed the nursing staff of the need to give preoperative medications. We deemed the following to be important medication classes: calcium channel blockers, neuromodulators, beta-blockers, anti-epileptics, digoxin, bronchodilators, anti-anginals, anti-epileptics, and benzodiazepines. This was re-audited after one month to assess compliance and monitor for improvement. Results Forty patients were included in the first round and 41 in the re-audit. In the first round, 16/41 (39%) patients received their medications correctly. In patients who did not receive their medications (n=25), 22 had important medication classes omitted. Post implementation of the posters, 25/41 (61%) patients received their medications correctly. In patients who did not receive their medications (n=16), 10 had important medication classes omitted. The main reason why medications were incorrectly not given was that patients were NPO. Conclusion This quality improvement audit shows that our interventions between audit cycles have made a significant improvement in patients receiving their medications and therefore this has a direct positive impact on patient safety and outcomes. We should continue to have a close rapport with the nursing staff to maintain standards of correct practice, and these audit findings should be escalated to the emergency theatre thereafter.

Association between preoperative use of antithrombotic medications and intraoperative transfusion in older patients undergoing cancer surgery

BACKGROUND

Management of antiplatelet agents and other chronic anticoagulation medications in patients scheduled for surgery can reduce intraoperative bleeding complications. However, few studies on the association of antithrombotics, relative to their duration of action, with intraoperative transfusion have been conducted. We aimed to determine the association of recent use of antithrombotics, relative to their duration of action, with intraoperative transfusion in elderly people undergoing cancer surgery.

METHODS

The study subjects were patients aged 65 years or older who were scheduled for cancer surgery and presented for comprehensive geriatric assessment. We reviewed the baseline patient characteristics obtained from electronic medical records and the patients' preoperative medication history, including anticoagulants, antiplatelet agents, and streptokinase/streptodornase.

RESULTS

A total of 475 cancer patients were included. Multivariate analysis showed that long-acting anticoagulant therapy before surgery was a significant risk factor for intraoperative transfusion. Long-acting anticoagulants increased the risk of transfusion approximately 15.9-fold (95% CI 1.9-136.2). The attributable risk of long-acting anticoagulants to transfusion was approximately 93.7%. Also, low body mass index (BMI) and hepato-pancreato-biliary (HPB) surgery were significantly associated with intraoperative transfusion. The adjusted odds ratios for low BMI (<18.5 kg/m²) and HPB surgery (reference: lower gastrointestinal surgery) were 5.3 (95% CI 1.8-15.4) and 4.9 (95% CI 1.9-12.5), respectively.

CONCLUSIONS

It was found that the perioperative use of long-acting anticoagulants was associated with an increased risk of intraoperative transfusion, further highlighting the importance of medication optimization for elderly patients with cancer surgery.

Management of antithrombotic agents in patients undergoing flexible bronchoscopy

Bleeding is one of the most feared complications of flexible bronchoscopy. Although infrequent, it can be catastrophic and result in fatal outcomes. Compared to other endoscopic procedures, the risk of morbidity and mortality from the bleeding is increased, as even a small amount of blood can fill the tracheobronchial tree and lead to respiratory failure. Patients using antithrombotic agents (ATAs) have higher bleeding risk. A thorough understanding of the different ATAs is critical to manage patients during the peri-procedural period. A decision to stop an ATA before bronchoscopy should take into account a variety of factors, including indication for its use and the type of procedure. This article serves as a detailed review on the different ATAs, their pharmacokinetics and the pre- and post-bronchoscopy management of patients receiving these medications.

Perioperative management of patients on direct oral anticoagulants

Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.

Current status of pharmacologic therapies in patient blood management

Patient blood management(1,2) incorporates patient-centered, evidence-based medical and surgical approaches to improve patient outcomes by relying on the patient's own (autologous) blood rather than allogeneic blood. Particular attention is paid to preemptive measures such as anemia management. The emphasis on the approaches being "patient-centered" is to distinguish them from previous approaches in transfusion medicine, which have been "product-centered" and focused on blood risks, costs, and inventory concerns rather than on patient outcomes. Patient blood management(3) structures its goals by avoiding blood transfusion(4) with effective use of alternatives to allogeneic blood transfusion.(5) These alternatives include autologous blood procurement, preoperative autologous blood donation, acute normovolemic hemodilution, and intra/postoperative red blood cell (RBC) salvage and reinfusion. Reviewed here are the available pharmacologic tools for anemia and blood management: erythropoiesis-stimulating agents (ESAs), iron therapy, hemostatic agents, and potentially, artificial oxygen carriers.

A reappraisal of plasma, prothrombin complex concentrates, and recombinant factor VIIa in patient blood management

Plasma therapy and plasma products such as prothrombin complex concentrates (PCCs), and recombinant activated factor VII (rFVIIa) are used in the setting of massive or refractory hemorrhage. Their roles have evolved because of newly emerging options, variable availability, and heterogeneity in guidelines. These factors can be attributable to lack of evidence-based support for a defined role for plasma therapy, variability in coagulation factor content among PCCs, and uncertainty regarding safety and efficacy of rFVIIa in these settings. This review summarizes these issues and provides insight regarding use of these options in management of refractory or massive bleeding.