Saturday, 19. of April 2014
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Perioperative management of anticoagulation

“A particularly frustrating aspect of anticoagulation therapy is the management of dosing when an invasive procedure is required”, said Jack Ansell, MD, Chairman Department of Medicine, Lenox Hill Hospital, New York.

A decision to use or not to use an alternative short-acting anticoagulant (called “bridging therapy”) in the peri-operative period is based on the perceived risk of thrombosis if the anticoagulant is stopped, or the risk of bleeding from an alternative short-acting anticoagulant. The number of variables is so great that it is not surprising that large, randomized, controlled trials, from which one could assess various alternative therapeutic interventions, have not been performed. “The bridging therapy is easy to do, but it is hard to know when it should be done,“ Ansell emphasized, before describing different approaches to performing a risk assessment.

The traditional management of peri-operative anticoagulation involves a brief pre- and post-operative infusion of unfractionated heparin, when an alternative is needed after oral anticoagulants are discontinued several days before the procedure. “Such a therapy requires an in-patient admission, and is costly, labor intensive, inconvenient, and carries potential risk,” said Ansell. “Low molecular weight heparin (LMWH) offers a simpler alternative, because subcutaneous, unmonitored therapy can be delivered at home.”

Finally, the physician managing the patient’s oral anticoagulation must arrive at an agreement with the physician performing the procedure. For some surgeons or interventionalists, the fear of bleeding if anticoagulation is continued during a procedure may outweigh the concern about thrombo-embolism if anticoagulation is discontinued. “Thus, even when the literature indicates that oral anticoagulation can be continued, the process may be one of negotiation and compromise with the physician performing the procedure,” said Ansell.

Report by Thomas Klein, MD, MSc (Nov. 2009)