Which patients should receive bridging anticoagulation the hospitalist gas pump heaven


A 77-year-old woman with a history of stroke five months prior, bileaflet aortic valve prosthesis, hypertension, and insulin-dependent diabetes is admitted for laparoscopy with lysis of adhesions. The patient stopped her warfarin 10 days prior to admission and initiated enoxaparin five days later. When should the enoxaparin be discontinued?

Many patients gas upper back pain receive chronic oral anticoagulant therapy to minimize their long-term risk of thromboembolic disease. Hospitalists and outpatient providers often care for such patients who need to undergo a medical procedure or operation. The risk of bleeding associated with the medical procedure necessitates an interruption in the patient’s chronic oral anticoagulant therapy. In this scenario, providers are faced with several therapeutic decisions:

‘Bridge’ anticoagulant gas in back and chest therapy is the administration of a short-acting parenteral anticoagulant during the peri-operative period, when the patient is not taking chronic oral anticoagulant. 1 The intent of bridge anticoagulant therapy is to minimize both the risk of thromboembolic events and the risk of bleeding during the peri-operative period. Bridging anticoagulant electricity questions for class 10 therapy is appropriate for some but not all patients undergoing medical procedures.

When to discontinue warfarin? Warfarin, the most commonly prescribed oral anticoagulant, achieves its therapeutic effects by antagonizing the actions of endogenous vitamin K-dependent coagulation factors. The decision on when to stop warfarin prior to surgery is dependent on the regeneration time of coagulation factors following the discontinuation of warfarin therapy. Although warfarin’s half-life is typically 36-42 hours, its therapeutic effects typically last up to five days in healthy subjects and often longer in elderly patients. 2

Current guidelines recommend the discontinuation of warfarin at least five days prior to surgery (Grade 1C recommendation). 3 Despite this recommendation, approximately 7% of patients electricity history facts will still have an international normalized ratio (INR) 1.5 after not taking warfarin for five days. 4 For this reason, the guidelines recommend that geothermal electricity how it works all patients have their INR checked on the day of surgery. For those patients with an INR of 1.5 to 1.9 on the day prior to surgery, there is evidence to show that administration of 1 mg of vitamin K will lower the INR to 1.4 in greater than 90% of cases. 5

Assessment of peri-procedural thrombotic risk. Knowledge of a patient’s past medical history is critical in helping providers stratify the patient’s peri-procedural thrombotic risk. According to the 2012 American College of Chest Physicians (ACCP) guidelines, a history of atrial fibrillation (Afib), mechanical heart valve(s), and previous VTE are independent risk factors for peri-procedural thrombotic events. 3 Hospitalists may risk-stratify their patients based on the anticipated annualized rate of thrombosis or embolization: 15% for youtube gas laws the respective low, medium, and high-risk groups. 6

Patients with Afib history. For these patients, the CHADS2 score helps to stratify the risk gas and water socialism of peri-procedural thrombosis. Low risk is defined as a CHADS2 score of zero to two, assuming that the two points were not scored for transient ischemic attack (TIA) or cerebrovascular accident (CVA). Any patient with a TIA or CVA within the previous three months is automatically considered high risk. Medium risk is a score of three or four.

Presence of mechanical heart valve(s). For patients with a mechanical heart valve, knowledge of the valve type and location is essential to assist hospitalists in stratifying the risk of peri-procedural thrombosis. The current ACCP guidelines consider patients with bileaflet aortic valve prostheses without additional risk factors for stroke or atrial fibrillation to be low risk. 3

Assessment specjalizacja z gastroenterologii of bleeding risk. Hospitalists must identify any preexisting bleeding risk factors (i.e., hemophilias or thrombocytopenia) in addition to the post-procedural bleeding risks. Risk factors for increased post-procedural bleeding include: major surgery with extensive tissue injury, procedures involving highly vascularized organs gas prices, removal of large colonic polyps, urological procedures, placement of implantable cardioverter-defibrillator/pacemakers, and procedures at sites where minor bleeding would be clinically devastating, such as the brain or spine. 3

Should the patient receive bridging anticoagulation? Patients considered high risk for peri-procedural thrombosis should receive peri-procedural bridging anticoagulation therapy, while those considered low risk should not. For patients with a moderate peri-procedural risk of thrombosis, hospitalists should electricity nightcore base the decision on individual and anticipated pre-surgical/procedural thrombotic risks.

Selection and pre-operative discontinuation of bridging medication. Current ACCP guidelines only support the use of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) as bridging anticoagulants. 3 Evidence supports the use of either intravenous UFH (goal aPTT 1.5 to two times control aPTT) or enoxaparin (1 mg/kg BID or 1.5 mg/kg once daily). 9 UFH is preferred over LMWH in patients with chronic kidney disease stage IV or V due to a more predictable pharmacokinetic profile.

When to restart UHF or LMWH bridge post-procedure. The type of procedure being performed dictates when bridging anticoagulation should resume. In patients who have undergone surgeries that involve high bleeding risk, LMWH should not be administered electricity outage chicago until 48-72 hours post-surgery (Grade 2C evidence). 3 For those patients undergoing surgeries with low bleeding risk, bridging should be resumed approximately 24 hours after the procedure.

When to restart long-term vitamin K antagonists (VKA) post-procedure. In most instances, regardless of pre-operative bleeding risk stratification, the resumption electricity bill cost per unit of VKA may occur once post-operative hemostasis has been achieved and the patient has been instructed to resume eating by the proceduralist or surgeon. This most often occurs on the calendar day following surgery, because it takes approximately five days for an INR to achieve therapeutic levels.

Although the patient underwent the operation without significant bleeding, the adjustment from an exploratory laparoscopy to an open laparotomy increased her gas 6 weeks pregnant post-operative bleeding risk from medium to high. Therefore, bridging anticoagulation with LMWH was resumed no sooner than 48 hours after the operation. Her warfarin was restarted on the day following surgery, once she resumed her diet.