Special situations that may influence perioperative antithrombotic management
| Situation or issue . | Comments . | Suggested actions . |
|---|---|---|
| Urgent/emergent procedures | • If there is not adequate time to allow natural normalization of the patient's coagulation status before surgery, use of reversal agents, prohemostatic agents, or specific antidotes may be indicated and should be done judiciously and thoughtfully. • Rapidly returning a patient to their native, prothrombotic state along with any intrinsic risk of thrombosis posed by the reversal agents or antidotes themselves may increase the risk for adverse events. | • Shared decision making with the patient, multidisciplinary discussion, and consultation with a thrombosis specialist • Clinicians are referred to existing guidance on reversal of anticoagulation.40,45,46 |
| Patients on concomitant antiplatelet therapies | • This is an opportune time to evaluate the overall clinical necessity of concomitant antiplatelet therapy. If not indicated, clinicians should discuss permanent discontinuation with the patient and prescriber. • Whether to temporarily interrupt concomitant antiplatelet therapies is a complex decision that is based on several factors, including indication, recency of events, bleeding, and thrombotic risks of the procedure and patient. • Perioperative antiplatelet strategies should be individually tailored based on multidisciplinary input. | • Shared decision making with the patient, multidisciplinary discussion, and consultation with prescriber of antiplatelet therapy (eg, cardiologist, neurologist) and thrombosis specialist • Clinicians are referred to existing guidance on perioperative antiplatelet management.47,48 |
| History of heparin-induced thrombocytopenia (HIT) | • Patients with a history of HIT should not receive any heparin or LMWH products, including small doses such as flushes or VTE prophylaxis. | • Use an alternative, nonheparin anticoagulant such as bivalirudin, fondaparinux, or a DOAC as appropriate based on patient's clinical status and clinical situation. • Clinicians are referred to existing guidance on HIT.49 |
| Inferior vena cava (IVC) filters | • The estimated incidence of VTE recurrence in the first month after an acute event off of anticoagulant therapy is estimated to be 40%.50 • If possible, delay nonurgent/emergent procedures to allow at least 3 months of anticoagulation therapy following an acute VTE. • If the procedure cannot be delayed and the VTE occurred in the previous 30 days, a retrievable IVC filter may be considered. | • If the patient is anticipated to be off anticoagulation for <48 hours, aggressive pharmacologic prophylaxis with expedient escalation to therapeutic dosing is preferred. • If a retrievable filter is considered, a plan for timely removal should be clearly delineated prior to placement. • Clinicians are referred to existing guidance on IVC filters.51 |
| Severe renal impairment | • Warfarin patients with severe renal impairment or on hemodialysis who have a clear indication for bridging cannot be managed with LMWH. | • These patients may need to have their warfarin held at a prespecified time in the outpatient setting and then be admitted for bridging therapy with intravenous heparin. |
| Situation or issue . | Comments . | Suggested actions . |
|---|---|---|
| Urgent/emergent procedures | • If there is not adequate time to allow natural normalization of the patient's coagulation status before surgery, use of reversal agents, prohemostatic agents, or specific antidotes may be indicated and should be done judiciously and thoughtfully. • Rapidly returning a patient to their native, prothrombotic state along with any intrinsic risk of thrombosis posed by the reversal agents or antidotes themselves may increase the risk for adverse events. | • Shared decision making with the patient, multidisciplinary discussion, and consultation with a thrombosis specialist • Clinicians are referred to existing guidance on reversal of anticoagulation.40,45,46 |
| Patients on concomitant antiplatelet therapies | • This is an opportune time to evaluate the overall clinical necessity of concomitant antiplatelet therapy. If not indicated, clinicians should discuss permanent discontinuation with the patient and prescriber. • Whether to temporarily interrupt concomitant antiplatelet therapies is a complex decision that is based on several factors, including indication, recency of events, bleeding, and thrombotic risks of the procedure and patient. • Perioperative antiplatelet strategies should be individually tailored based on multidisciplinary input. | • Shared decision making with the patient, multidisciplinary discussion, and consultation with prescriber of antiplatelet therapy (eg, cardiologist, neurologist) and thrombosis specialist • Clinicians are referred to existing guidance on perioperative antiplatelet management.47,48 |
| History of heparin-induced thrombocytopenia (HIT) | • Patients with a history of HIT should not receive any heparin or LMWH products, including small doses such as flushes or VTE prophylaxis. | • Use an alternative, nonheparin anticoagulant such as bivalirudin, fondaparinux, or a DOAC as appropriate based on patient's clinical status and clinical situation. • Clinicians are referred to existing guidance on HIT.49 |
| Inferior vena cava (IVC) filters | • The estimated incidence of VTE recurrence in the first month after an acute event off of anticoagulant therapy is estimated to be 40%.50 • If possible, delay nonurgent/emergent procedures to allow at least 3 months of anticoagulation therapy following an acute VTE. • If the procedure cannot be delayed and the VTE occurred in the previous 30 days, a retrievable IVC filter may be considered. | • If the patient is anticipated to be off anticoagulation for <48 hours, aggressive pharmacologic prophylaxis with expedient escalation to therapeutic dosing is preferred. • If a retrievable filter is considered, a plan for timely removal should be clearly delineated prior to placement. • Clinicians are referred to existing guidance on IVC filters.51 |
| Severe renal impairment | • Warfarin patients with severe renal impairment or on hemodialysis who have a clear indication for bridging cannot be managed with LMWH. | • These patients may need to have their warfarin held at a prespecified time in the outpatient setting and then be admitted for bridging therapy with intravenous heparin. |