Tag Archives: Perioperative Care

Timing of elective surgery and risk assessment after SARS-CoV-2 infection

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“Patients who develop symptoms of SARS-CoV-2 infection within 7 weeks of planned surgery, including on the day of surgery, should be screened for SARS-CoV-2. Elective surgery should not usually be undertaken within 2 weeks of diagnosis of SARS-CoV-2 infection. For patients who have recovered from SARS-CoV-2 infection and who are low risk or having low-risk surgery, most elective surgery can proceed 2 weeks following a SARS-CoV-2 positive test. For patients who are not low risk or having anything other than low-risk surgery between 2 and 7 weeks following infection, an individual risk assessment must be performed. This should consider: patient factors (age; comorbid and functional status); infection factors (severity; ongoing symptoms; vaccination); and surgical factors (clinical priority; risk of disease progression; grade of surgery).”

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Periprocedural bridging anticoagulation

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Rechenmacher SJ, Fang JC. Bridging Anticoagulation: Primum Non Nocere. J Am Coll Cardiol. 2015 Sep 22;66(12):1392-403.

Full-text for Emory users.

Conclusions: Periprocedural anticoagulation management is a common clinical dilemma with limited evidence (but 1 notable randomized trial) to guide our practices. Although bridging anticoagulation may be necessary for those patients at highest risk for TE, for most patients it produces excessive bleeding, longer length of hospital stay, and other significant morbidities, while providing no clear prevention of TE. Unfortunately, contemporary clinical practice, as noted in physician surveys, continues to favor interruption of OAC and the use of bridging anticoagulation. While awaiting the results of additional randomized trials, physicians should carefully reconsider the practice of routine bridging and whether periprocedural anticoagulation interruption is even necessary.

Central Illustration. Bridging Anticoagulation: Algorithms for Periprocedural Interrupting and Bridging Anticoagulation. Decision trees for periprocedural interruption of chronic oral anticoagulation (top) and for periprocedural bridging anticoagulation (bottom). OAC = oral anticoagulation.

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Management of malignant hyperthermia

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Hopkins PM, Girard T, Dalay S, Jenkins B, Thacker A, Patteril M, McGrady E. Malignant hyperthermia 2020: Guideline from the Association of Anaesthetists. Anaesthesia. 2021 May;76(5):655-664. Free full-text.

Kim KSM, Kriss RS, Tautz TJ. Malignant Hyperthermia: A Clinical Review. Adv Anesth. 2019 Dec;37:35-51. Full-text for Emory users.

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Guidelines for the perioperative management of anticoagulants

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One discussion this week focused on the perioperative management of NOACs.

Reference:  DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. 227537, Periprocedural management of patients on long-term anticoagulation; [updated 2018 Oct 10, cited 2018 Oct 12; [about 26 screens]. Emory login required.

Summary: The information below is from DynaMed Plus (2018). To view full information on the topic, click on the citation above.

Vitamin K antagonists in patients undergoing major surgery or procedures

  • Consider continuing vitamin K antagonist (VKA) therapy in patients who require minor dental procedures, minor dermatological procedures, or cataract surgery.
  • In those having a minor dental procedure, consider coadministering an oral hemostatic agent or stopping the VKA 2 to 3 days before the procedure.
  • In those undergoing implantation of a pacemaker or an implantable cardioverter device, consider continuing VKA therapy.
  • In those having a major surgery or procedure, stop VKA therapy 5 days before surgery.
  • Resume VKA therapy 12-24 hours after surgery when there is adequate hemostasis.

Bridging therapy in patients undergoing major surgery or procedures

  • If at low risk for thrombosis, consider omitting bridging therapy.
  • If at moderate risk for thrombosis, assess individual patient- and surgery-related factors when considering bridging therapy.
  • If at high risk for thrombosis consider bridging therapy with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH).
  • For those receiving bridging therapy with UFH, stop UFH 4-6 hours before surgery.
  • For those receiving bridging therapy with therapeutic-dose LMWH, stop LMWH 24 hours before surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing non-high-bleeding-risk surgery, consider resuming heparin 24 hours after surgery.
  • For those receiving bridging therapy with UFH or therapeutic-dose LMWH and undergoing high-bleeding-risk surgery, consider resuming heparin 48-72 hours after surgery.

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Perioperative Management of Biologic and Immunosuppressive Medications in Patients With Crohn’s Disease

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Lightner AL. Perioperative Management of Biologic and Immunosuppressive
Medications in Patients With Crohn’s Disease. Dis Colon Rectum. 2018 Apr;61(4): 428-431.

EVALUATION AND TREATMENT ALGORITHMS

Algorithm 1

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The PAUSE study: Safety of perioperative DOAC management in patients with atrial fibrillation

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A discussion during a previous conference included the perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant (DOAC).

Reference: Douketis JD, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Internal Medicine. 2019 Aug 5; doi:10/1001/jamainternmed.2019.2431

Summary: Each year, 1 in 6 patients with AF, or an estimated 6 million patients worldwide, will require perioperative anticoagulant management. When DOAC regimens became available for clinical use in AF, starting in 2010, no studies had been conducted to inform the timing of perioperative DOAC therapy interruption and resumption, whether heparin bridging should be given, and whether preoperative coagulation function testing was needed. Uncertainty about the perioperative management of DOACs may be associated with unsubstantiated practices and increased harm to patients.

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