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Perioperative Anticoagulation Management 

Perioperative Anticoagulation Management 

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In performing noncardiac surgery on patients on anticoagulation, the major concern is when it is safe to perform surgery without increasing the risk of hemorrhage or increasing the risk of thromboembolism (eg, venous, arterial) after discontinuing treatment. In treating patients on long-term warfarin (Coumadin) perioperatively, consider the risks of hemorrhage or thromboembolism versus the benefit from the operation. When considering noncardiac surgery, these factors and the need to weigh the risk of hemorrhage against that of thromboembolism must be analyzed on an individual patient basis. Certain procedures (eg, oncologic procedures, threats to limb or life) are easy analyses. More complex discussions must be had for such cases as hernia repair of other elective nonurgent operations.

The approach options for these patients can be one of the following: continue warfarin therapy, withhold warfarin therapy for a period of time before and after the procedure, or temporarily withhold warfarin therapy and also provide a “heparin bridge” during the perioperative period. Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure.

The American College of Chest Physicians proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the annual risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.

Patients with prosthetic heart valves pose a particular problem. Arterial thromboembolism from the heart often results in death (40% of events) or major disability (20% of events). The greatest problem encountered is that no consensus exists regarding the optimal perioperative management of anticoagulation for patients who have been receiving long-term warfarin therapy. Some prospective studies have suggested that patients on long-term warfarin therapy who undergo minor invasive procedures and are taken off their oral anticoagulation for up to 5 days have a less than 1% risk of experiencing a thromboembolic event.

It has been suggested that patients on long-term warfarin therapy (including those with mechanical heart valves or atrial fibrillation) who are undergoing minor elective invasive outpatient procedures (eg, colonoscopy, dental procedures) may have a slightly increased risk of perioperative bleeding if placed in some form of heparin therapy (eg, heparin bridge) than those who have their oral anticoagulation withheld for 4-5 days (major hemorrhage 3.7% vs 0.2% and significant nonmajor hemorrhage 9% vs 0.6%, respectively). The perioperative risk of bleeding when using a heparin bridge appears to be higher and the risk of thromboembolic events appears to be lower when Coumadin is stopped than what is reported elsewhere in the literature.

N-acetylcysteine is known to impair hemostasis when used for the prevention of perioperative inflammation and ischemia-reperfusion injury. Wijeysundera et al sought to determine whether N-acetylcysteine is associated with increased blood loss and blood product transfusion in 89 patients with preexisting moderate renal insufficiency undergoing cardiac surgery. [1] Another 88 patients received placebo.

The investigators found patients in the N-acetylcysteine group had a 261-mL greater mean 24-hour chest-tube blood loss and received 1.6 units more of red blood cell transfusions than the placebo group. [1] In addition, there was a significantly higher risk of receiving 5 or more units of red blood cells within 24 hours of surgery in the patients receiving N-acetylcysteine compared with the placebo group (P = 0.005). Wijeysundera et al therefore recommended clinicians and researchers consider the potential of impaired hemostasis in using N-acetylcysteine in the perioperative setting. [1]

A 2014 randomized study by Di Biase was the first study showing that performing catheter ablation of atrial fibrillation (AF) without warfarin discontinuation reduces the occurrence of periprocedural stroke and minor bleeding complications compared with bridging with low-molecular-weight heparin (LMWH). [2]

A National Heart, Lung, and Blood Institute (NHLBI)–sponsored study showed that a periprocedural bridging strategy with low-molecular-weight heparin (LMWH) offered no clinical advantages compared with interrupting warfarin treatment. [3, 4]

The American College of Chest Physicians proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the annual risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.

The 8th and 9th edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines included the following key recommendations [5, 6] :

In patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE):

At high risk for thromboembolism, bridging anticoagulation is recommended with therapeutic-dose subcutaneous (SC) low-molecular-weight heparin (LMWH) or intravenous unfractionated heparin (UFH) rather than no bridging during temporary interruption of vitamin K antagonist (VKA) therapy. [7]

At moderate risk for thromboembolism, it is proposed to base the plan for bridging versus no bridging on the individual patient rather than a generalized consensus. The bridging anticoagulation can be done with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH based on the patient.

At low risk for thromboembolism, low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH is recommended.

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, the ACCP recommends to continue aspirin and clopidogrel in the perioperative period

In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, continuing aspirin and clopidogrel in the perioperative period is also recommended.

In patients on VKAs who are undergoing minor dental procedures, continue the VKAs around the time of the procedure as well as coadminister an oral prohemostatic agent.

In patients on VKAs who are undergoing minor dermatologic procedures or cataract removal, continue the VKAs perioperatively.

The table below depicts which patients should receive heparin bridging before surgery.

See the list below:

For excellent patient education resources, see eMedicineHealth’s patient education article Deep Vein Thrombosis (Blood Clot in the Leg, DVT).

See Deep Venous Thrombosis.

Any patient who is on long-term anticoagulation and is to undergo a major surgery needs proactive management. [8] Some authors believe that patients can be maintained on oral anticoagulation for minor procedures, such as dental extractions, biopsies, ureterorenoscopy, Ho:YAG lithotripsy, and ophthalmic operations, as long as the therapeutic range of the prothrombin time (PT) value is not greater than 2.5. [9] A recently published study revealed a higher rate of hemorrhagic complications after glaucoma surgery in patients on anticoagulation or antiplatelet therapy. Patients who continued anticoagulation during glaucoma surgery had a hemorrhagic complication rate of 31.8% compared to 3.7% of patients with no anticoagulation or antiplatelet therapy. [10] Local bleeding with dental surgery may be controlled with tranexamic acid mouthwash orepsilon aminocaproic acid mouthwash.

The American Society of Gastrointestinal Endoscopy divided endoscopic procedures into low and high risk for bleeding in its 2002 guidelines on anticoagulation. Low bleeding-risk endoscopic procedures do not require a change in anticoagulation.

Low bleeding-risk endoscopic procedures are as follows:

Upper endoscopy with or without biopsy

Flexible sigmoidoscopy with or without biopsy

Colonoscopy with or without biopsy

Endoscopic retrograde cannulation of the pancreatic duct without sphincterotomy

Biliary stent insertion without sphincterotomy

Endosonography without fine-needle aspiration

Push enteroscopy of the small bowel

High bleeding-risk endoscopic procedures are as follows:

Polypectomy

Laser ablation and coagulation

Endoscopic sphincterotomy

Pneumatic or bougie dilation

Percutaneous endoscopic gastrostomy tube placement

Treatment of varices

In general, antithrombotic therapy is indicated for venous thromboembolic disease (ie, deep venous thrombosis [DVT]; pulmonary embolism [PE]; primary prophylaxis of DVT or PE; antithrombin III [ATIII], protein C, and protein S deficiency); arterial thromboembolic disease (ie, prosthetic heart valves, atrial fibrillation, congestive cardiomyopathies, mural cardiac thrombus, acute myocardial infarction, mitral valve disease); disseminated intravascular coagulation; and maintaining patency of vascular grafts, shunts, and bypasses. [11, 12]

Currently, it is generally recommended that patients with the highest risk of arterial or venous thromboembolism, who require interruption of oral anticoagulant therapy for surgery, should receive therapeutic-dose heparin therapy (eg, unfractionated heparin [UFH], low molecular weight heparin [LMWH]) during much of the interval when the international normalized ratio (INR) is subtherapeutic.

Usually, unless accompanied by significant cardiomyopathy or recent arterial embolus, patients with atrial fibrillation can have their Coumadin stopped 4 days prior to surgery, then resumed at the usual dose the night of surgery.

Patients with prosthetic heart valves usually are treated with perioperative LMWH, although randomized controlled trials validating this method are lacking. Coumadin can be stopped 4-5 days preoperatively, with LMWH started the next day at a therapeutic dose. The last dose should be 12 hours preoperatively. LMWH and Coumadin can be retitrated the evening of the operative day. LMWH is stopped when the Coumadin reaches the target range. For patients at higher risk of valve thrombosis (ie, patients with 2 prosthetic valves or with caged-ball type of valves), whether LMWH provides adequate anticoagulant protection is unclear. For these patients, consider use of perioperative UFH instead of LMWH. Preoperatively, the heparin should be stopped 6 hours before the procedure. Postoperatively, the heparin can be restarted when the surgeon agrees that it is safe, usually 6-12 hours postoperatively.

Prophylactic and therapeutic doses of LMWH in perioperative anticoagulation management are tabulated below.

Contraindications to antithrombotic therapy are relative, and the risks and benefits need to be weighed. Relative contraindications are bleeding abnormality (eg, thrombocytopenia, platelet defect, peptic ulcer disease), CNS lesion (eg, stroke, surgery, trauma), spinal anesthesia or lumbar puncture, malignant hypertension, and advanced retinopathy. Contraindications specific to warfarin are early or late pregnancy, poor patient cooperation, and occupational risk. LMWH should be avoided in patients with renal insufficiency, because it is cleared primarily by the kidney. If used, the anticoagulant effect of LMWH should be measured with an antifactor Xa level done 4 hours after the LMWH dose. The targeted therapeutic antifactor Xa level is 0.5-1.5 U/mL.

See Deep Venous Thrombosis.

Several protocols have been developed to care for patients taking oral anticoagulants. Regardless of the protocol used, the period of subtherapeutic oral anticoagulation should be kept to a minimum in patients with previous embolism and in others who are at highest risk for embolism. Kearon formulated a preoperative and postoperative strategy divided into sites of embolic disease. [13] His recommendations are summarized below.

In patients with previous arterial embolism, only 4 daily doses of warfarin should be withheld preoperatively and the INR should be measured the day before surgery to determine if a small dose of vitamin K is needed to accelerate the reversal of anticoagulation. If the INR is more than 1.7 on the day before surgery, administer 1 mg of vitamin K subcutaneously and repeat the INR the morning of the surgery. If on the day of surgery the INR is 1.3-1.7, administer 1 unit of frozen plasma; administer 2 units of frozen plasma if the INR is 1.7-2. The active reversal of oral anticoagulants should be discouraged in patients with mechanical valves, especially with the use of fresh frozen plasma.

For a patient who has had an arterial thromboembolism within a month of surgery, start intravenous UFH when the INR drops to less than 2 to minimize the risk of recurrent embolism. Discontinue the intravenous heparin 6 hours before surgery.

After an acute episode of venous thromboembolism (VTE), defer surgery, if feasible, until patients have received at least 1 month, and preferably 3 months, of anticoagulation. If surgery must be performed within 1 month of an acute VTE, intravenous UFH should be administered while the INR is less than 2. If surgery must be performed within 2 weeks after an acute episode, intravenous heparin may be withheld 6 hours preoperatively and 12 hours postoperatively, if the surgery is short. If the acute event was within 2 weeks of major surgery and/or patients have a higher risk of postoperative bleeding, a vena caval filter should be inserted preoperatively or intraoperatively.

Warfarin should be withheld for only 4 doses if the most recent episode of VTE occurred 1-3 months before surgery. If the patient has been anticoagulated for 3 or more months, 5 doses of warfarin can be withheld before surgery. Preoperatively, subcutaneous UFH or LMWH is needed only for immobilized inpatients with an INR of less than 1.8.

Jaffer formulated the Cleveland Clinic Anticoagulation Clinic Protocol and defined the following 3 risk categories for thromboembolism: [14]

High – 1-year risk of arterial embolism greater than 10%, or 1-month risk of venous thromboembolism greater than 10%

Intermediate – 1-year risk of arterial embolism greater than 5-10%, or 1-month risk of venous thromboembolism at 2-10%

Low – 1-year risk of arterial embolism less than 5%, or 1-month risk of venous thromboembolism less than 2%

The table below gives a protocol for LMWH as a bridge to surgery in patients on warfarin.

Lai addresses perioperative management of patients on new oral anticoagulants. Novel oral anticoagulants (NOACs) offer an alternative to warfarin for preventing stroke in patients with atrial fibrillation. Management of NOACs in elective and emergency conditions requires knowledge of time of last intake of drug, current renal function, and the planned procedure in order to assess the overall risk of bleeding. [15]

The first of several NOAC reversal agents, idarucizumab (Praxbind), was approved by the FDA in October 2015. Idarucizumab is a monoclonal antibody that binds specifically to dabigatran (it does not affect other NOACs). It is approved for patients treated with dabigatran when reversal of the anticoagulant effects are needed for emergency surgery or urgent procedures, or in the event of life-threatening or uncontrolled bleeding.

Accelerated approval for idarucizumab was based on interim analysis of the Re-VERSE AD trial. Investigators found that, among 39 patients who had been receiving dabigatran and required an urgent procedure were then given idarucizumab, 36 underwent their urgent procedure—with 33 (92%) having normal hemostasis during the event. Two of the remaining patients had mildly abnormal bleeding (with slight oozing), while just one had moderately abnormal yet controlled bleeding. Among 35 of 51 patients who had serious bleeding were able to be assessed, hemostasis, as determined by local investigators, was restored at a median of 11.4 hours. [16]

In May 2018, coagulation factor Xa recombinant (AndexXa) was approved for patients treated with rivaroxaban or apixaban, when reversal of anticoagulation is needed because of life-threatening or uncontrolled bleeding. Approval was supported by data from two Phase 3 ANNEXA studies (ANNEXA-R and ANNEXA-A), which evaluated the safety and efficacy of Andexxa in reversing the anticoagulant activity of the Factor Xa inhibitors rivaroxaban and apixaban in healthy older volunteers. Results demonstrated a rapid and significant reversal of anti-Factor Xa (FXa) activity. Anti-FXa activity was reduced among apixaban-treated participants by 94% compared with 21% for placebo (p<0.001). A 92% reduction of anti-FXa activity was observed in the rivaroxaban-treated participants compared with 18% for placebo (p<0.001).<ref>23</ref>

In the ANNEXA-4 trial, 67 patients who had acute major bleeding within 18 hr after administration of an FXa inhibitor received coagulation factor Xa recombinant. After the IV bolus plus 2 hour IV infusion, the median anti-FXa activity decreased by 89% from baseline among patients receiving rivaroxaban and by 93% among patients receiving apixaban. Assessment at 12 hours after the infusion adjudicated clinical hemostasis as excellent or good in 37 of 47 patients in the efficacy analysis (79%; 95% CI, 64 to 89). Thrombotic events occurred in 12 of 67 patients (18%) during the 30-day follow-up. [24]

If surgery is performed within 1 month after an episode of arterial thromboembolism, intravenous heparin is warranted until the INR reaches 2 if the risk of bleeding is not very high. Administer intravenous UFH without a loading dose 12 hours after surgery at a rate of no more than 18 U/kg/h. Defer the first activated partial thromboplastin time (aPTT) for 12 hours to attain a stable anticoagulant response. Postoperative intravenous heparin is not recommended for patients who undergo major surgery and who are at high risk for anticoagulant-induced bleeding, even if an episode of arterial embolism has occurred within 1 month before surgery. Instead, administer subcutaneous UFH or LMWH (3000 U bid) until the INR reaches 1.8.

If the patient had an episode of VTE within 3 months before surgery, intravenous UFH is recommended until the INR is greater than or equal to 2. Patients who have a vena caval filter are protected from pulmonary embolism, and intravenous heparin can be avoided in their early postoperative period. If no previous episodes of VTE occurred within 3 months, postoperative intravenous heparin is not indicated. Subcutaneous heparin is recommended.

Madura et al recommend discontinuing Coumadin 5 days before surgery and beginning intravenous heparin at 1000 U/h, while adjusting to maintain the aPTT at therapeutic levels. [17] Heparin is discontinued 6-12 hours before surgery and restarted at 200-400 U/h at 4-6 hours after surgery. Coumadin is restarted as soon as tolerated by the patient.

Stop oral anticoagulants at least 5 days preoperatively, and do not perform the procedure until the PT is in the reference range. Substitute intravenous heparin infusion for oral anticoagulant therapy preoperatively to prevent thromboembolic complications in the perioperative period. Stop the intravenous heparin infusion 6-12 hours preoperatively to allow the aPTT to return to normal for adequate intraoperative hemostasis. Restart the intravenous heparin infusion within 6 hours of completion of the surgical procedure to prevent postoperative thromboembolism. Resume oral Coumadin therapy as soon as the patient is able to tolerate oral liquids. Do not release the patient until the PT is once again in the therapeutic range.

Perioperative management of anticoagulation entails an understanding of all thromboembolic events, indications for treatment, and duration of treatment. [18, 19, 20] The American College of Chest Physicians for Prevention of Thromboembolism published the following guidelines. [21] An updated guideline was published in 2008 [5] and 2012 [6] . A full listing is available at American College of Chest Physicians.

Low-risk general surgery patients – Early ambulation

Moderate-risk general surgery patients – Low-dose unfractionated heparin (LDUH), LMWH, intermittent pneumatic compression (IPC), or elastic stockings (ES)

Higher-risk general surgery patients – LDUH or higher-dose LMWH

Higher-risk general surgery patients prone to wound complications (eg, hematomas, infection) – IPC is an alternative.

Very high-risk general surgery patients with multiple risk factors – LDUH or LMWH combined with IPC

Selected very high-risk general surgery patients – Perioperative warfarin (goal INR 2.5, range 2-3)

Patients undergoing total hip replacement surgery – LMWH started 12-24 hours after surgery or warfarin started before or immediately after surgery (goal INR 2.5, range 2-3) if adjusted-dose heparin is started preoperatively; possible adjuvant use of ES or IPC

Patients undergoing total knee replacement surgery – LMWH, warfarin, or IPC

Patients undergoing hip fracture surgery – LMWH or warfarin (goal INR 2.5, range 2-3) started preoperatively or immediately after surgery

High-risk patients undergoing orthopedic surgery – Inferior vena cava (IVC) filter placement only if other forms of anticoagulant-based prophylaxis are not feasible because of active bleeding (should rarely be necessary)

Patients undergoing intracranial neurosurgery – IPC with or without ES; LMWH and LDUH may be acceptable alternatives; consider IPC or ES, with LMWH or LDUH, for high-risk patients

Patients with acute spinal cord injury – LMWH; although ES and IPC appear ineffective when used alone, ES and IPC may have benefit when used with LMWH or if anticoagulants are contraindicated; during rehabilitation, consider continuation of LMWH or conversion to full-dose oral anticoagulation

Trauma patients with an identifiable risk factor for thromboembolism – LMWH, as soon as considered safe; consider initial prophylaxis with IPC if administration of LMWH is delayed or is contraindicated; in high-risk patients with suboptimal prophylaxis, consider screening with duplex ultrasonography or filter placement in the IVC

Patients with myocardial infarction – LDUH or full-dose anticoagulation; IPC and possibly ES may be useful when heparin is contraindicated

Patients with ischemic stroke and lower extremity paralysis – LDUH or LMWH; IPC with ES also probably is effective

General medical patients with clinical risk factors for VTE, particularly those with congestive heart failure (CHF) or chest infections – LDUH or LMWH

Patients with long-term indwelling central vein catheters – Warfarin (1 mg/d) or daily LMWH to prevent axillary-subclavian venous thrombosis

Patients having spinal puncture or epidural catheters placed for regional anesthesia or analgesia – LMWH should be used with caution (additional data are now reported on timing of catheter removal), ES, LDUH

A retrospective study by Wamala et al that included 150 patients receiving new oral anticoagulants undergoing elective surgery reported that 41.5% of the decisions to interrupt anticoagulation were considered consistent with guidelines and based on low bleeding risk in all cases and high thrombotic risk in one-third. [22]  

Overview

Which risks must be considered in surgical patients taking anticoagulants?

What are the options for perioperative anticoagulation management?

According to the American College of Chest Physicians (ACCP) antithrombotic prophylaxis guidelines, when can warfarin be withheld in perioperative anticoagulation management?

What are the risks of warfarin therapy for perioperative anticoagulation management in patients with mechanical heart valves?

What are the risks of N-acetylcysteine in perioperative anticoagulation management?

What is the efficacy of a periprocedural bridging strategy with low-molecular-weight heparin (LMWH) for the management of anticoagulation?

What are the American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guidelines for perioperative anticoagulation management?

What is the pathophysiology of deep venous thrombosis relative to perioperative anticoagulation management?

What are the indications for perioperative anticoagulation management?

According to the American Society of Gastrointestinal Endoscopy, which endoscopic procedures do not require changes to perioperative anticoagulation management?

Which low bleeding-risk endoscopic procedures do not require changes to perioperative anticoagulation management?

According to the American Society of Gastrointestinal Endoscopy, which endoscopic procedures require changes to perioperative anticoagulation management?

When is antithrombotic therapy indicated in perioperative anticoagulation management?

What is the perioperative anticoagulation management for patients with prosthetic heart valves?

What are the prophylactic and therapeutic doses of LMWH for perioperative anticoagulation management?

What are the contraindications of antithrombotic therapy in perioperative anticoagulation management?

Which lab studies are needed for perioperative anticoagulation management?

What is the perioperative anticoagulation management of patients with previous arterial embolism?

What is the perioperative anticoagulation management of patients with venous thromboembolism (VTE)?

What are the risk categories for thromboembolism?

What is the protocol for use of LMWH as a bridge to surgery?

What is the role of novel oral anticoagulants (NOACs) in perioperative anticoagulation management?

What is the role of idarucizumab in perioperative anticoagulation management?

What is the role of coagulation factor Xa recombinant (AndexXa) in perioperative anticoagulation management?

What is the role of IV heparin in postoperative anticoagulation management?

What is the postoperative management of perioperative anticoagulation in patients with recent venous thromboembolism (VTE)?

What are the American College of Chest Physicians (ACCP) guidelines for perioperative management of anticoagulation?

What is the basis for decisions to interrupt anticoagulation during perioperative management?

Wijeysundera DN, Karkouti K, Rao V, et al. N-acetylcysteine is associated with increased blood loss and blood product utilization during cardiac surgery. Crit Care Med. 2009 Jun. 37(6):1929-34. [Medline].

Di Biase L, Burkhardt JD, Santangeli P, Mohanty P, Sanchez JE, Horton R, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management: results from the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) randomized trial. Circulation. 2014 Jun 24. 129(25):2638-44. [Medline].

Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Jun 22. [Medline].

O’Riordan M. BRIDGE: No Benefit From Perioperative LMWH in Patients With AF. Heartwire from Medscape. Available at http://www.medscape.com/viewarticle/846892. June 23, 2015; Accessed: August 19, 2015.

Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008 Jun. 133(6 suppl):299S-339S. [Medline]. [Full Text].

Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141(2 Suppl):e326S-50S. [Medline]. [Full Text].

Akl EA, Labedi N, Terrenato I, Barba M, Sperati F, Sempos EV, et al. Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Cochrane Database Syst Rev. 2011 Nov 9. 11:CD009447. [Medline].

Douketis JD. Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach. Hosp Pract (Minneap). 2011 Oct. 39(4):41-54. [Medline].

Turna B, Stein RJ, Smaldone MC, et al. Safety and efficacy of flexible ureterorenoscopy and holmium:YAG lithotripsy for intrarenal stones in anticoagulated cases. J Urol. 2008 Apr. 179(4):1415-9. [Medline].

Law SK, Song BJ, Yu F, et al. Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy. Am J Ophthalmol. 2008 Apr. 145(4):736-746. [Medline].

Garwood CL, Hwang JM, Moser LR. Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies. Pharmacotherapy. 2011 Dec. 31(12):1208-20. [Medline].

Nuttall MT, Rodgers GM. Perioperative management of antithrombotic therapy in cardiovascular patients. Methodist Debakey Cardiovasc J. 2011 Oct. 7(4):10-4. [Medline].

Kearon C. Perioperative management of long-term anticoagulation. Semin Thromb Hemost. 1998. 24 suppl 1:77-83. [Medline].

Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med. 2003 Nov. 70(11):973-84. [Medline].

Lai A, Davidson N, Galloway SW, Thachil J. Perioperative management of patients on new oral anticoagulants. Br J Surg. 2014 Jun. 101(7):742-9. [Medline].

Pollack CV Jr, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015 Aug 6. 373 (6):511-20. [Medline].

Madura JA, Rookstool M, Wease G. The management of patients on chronic Coumadin therapy undergoing subsequent surgical procedures. Am Surg. 1994 Jul. 60(7):542-6; discussion 546-7. [Medline].

Kraai EP, Lopes RD, Alexander JH, Garcia D. Perioperative management of anticoagulation: guidelines translated for the clinician. J Thromb Thrombolysis. 2009 Jul. 28(1):16-22. [Medline].

Scharf RE. Management of bleeding in patients using antithrombotic agents. Hamostaseologie. 2009 Sep. 29(4):388-98. [Medline].

Tanaka KA, Key NS, Levy JH. Blood coagulation: hemostasis and thrombin regulation. Anesth Analg. 2009 May. 108(5):1433-46. [Medline].

American College of Chest Physicians. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. 2004. 126(3 suppl):214S -215S.

Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J. 2017 Dec. 47 (12):1412-1421. [Medline].

Siegal DM, Curnutte JT, Connolly SJ, Lu G, Conley PB, Wiens BL, et al. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. N Engl J Med. 2015 Dec 17. 373 (25):2413-24. [Medline]. [Full Text].

Connolly SJ, Milling TJ Jr, Eikelboom JW, Gibson CM, Curnutte JT, Gold A, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors. N Engl J Med. 2016 Sep 22. 375 (12):1131-41. [Medline]. [Full Text].

American College of Chest Physicians. Proceedings of the American College of Chest Physicians 5th Consensus on Antithrombotic Therapy. 1998. Chest. 1998 Nov. 114(5 Suppl):439S-769S. [Medline].

Douketis JD. Perioperative anticoagulation management in patients who are receiving oral anticoagulant therapy: a practical guide for clinicians. Thromb Res. 2002 Oct 1. 108(1):3-13.

Garcia DA, Regan S, Henault LE, et al. Risk of thromboembolism with short-term interruption of warfarin therapy. Arch Intern Med. 2008 Jan 14. 168(1):63-9. [Medline].

Jafri SM. Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy. Am Heart J. 2004 Jan. 147(1):3-15. [Medline].

Lanzat M, Danna AT, Jacobson DS. New protocols for perioperative management of podiatric patients taking oral anticoagulants. J Foot Ankle Surg. 1994 Jan-Feb. 33(1):16-20. [Medline].

O’Donnell M, Kearon C. Perioperative management of oral anticoagulation. Clin Geriatr Med. 2006 Feb. 22(1):199-213, xi. [Medline].

Rutherford R. Fundamental therapeutic and technical consideration. Vascular Surgery. Philadelphia, Pa: WB Saunders Company; 1995.

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Dana Taylor, MD, FACS Assistant Professor of Surgery, University of Tennessee Health Science Center College of Medicine; Consulting Surgeon, University General Surgeons, PC

Dana Taylor, MD, FACS is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Southeastern Surgical Congress, Eastern Association for the Surgery of Trauma, American Medical Association

Disclosure: Nothing to disclose.

Jose Fernando Aycinena Goicolea, MD Colorectal Surgeon, The Longstreet Clinic

Jose Fernando Aycinena Goicolea, MD is a member of the following medical societies: American College of Surgeons, Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Donna Leco Mercado, MD, MD 

Donna Leco Mercado, MD, MD is a member of the following medical societies: Sigma Xi

Disclosure: Nothing to disclose.

William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke’s Medical Center

William A Schwer, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Senior Associate Dean for Medicine and Research, Professor of Surgery, Pathology, and Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, Sigma Xi

Disclosure: Nothing to disclose.

Perioperative Anticoagulation Management 

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