Management of Perioperative

Coagulopathy

Karmel LTambunan
Division of HOM Internal
Medicine Faculty of Medicine
Universitas Indonesia
 Perioperative Period

• Defined as the time :

- before (preoperative)
- during (intraoperative ) and
- after (postoperative ) the procedure
 Coagulopathy/Hematologic Risks

• Complications
– Bleeding
– Thromboembolic
 Hemostasis problems in surgical
patients
• Bleeding and thrombosis are the major
complication of any surgery
• Surgeon to be responsible for hemostasis both
during and after the operation
• All surgeon are trained to control visibly bleeding
vessel
• The experienced surgeon’s fingers is the best
hemostatic instrument
•E
d
 Preoperative assessment (1)
• History :
– Bleeding related to trauma, surgical, and dental
procedures
– Drugs or medications :
• Aspirin, warfarin
• Physis :
– Ptechiae, purpura, ecchymosis, hematoma
– Include bleeding tendency
– Comorbid disease :
• Uremia, cirrhosis, polycythemia
 Preoperative Evaluation
• The aim of preoperative evaluation is
not to screen broadly for undiagnosed
disease but rather to identify and
quantify any comorbidity that may
have an impact on the operative
outcome
 Preoperative assessment (2)
• Laboratorium :
– Major surgery : screening test, platelet count,
aPTT, PTT, fibrinogen
– A prolonged aPTT, or PTT, consultation with
hematologist is recommended.
 Thrombocytopenia

• Platelet count<140,000/mL
– DDX sepsis, drug induced, dilutional, DIC
 Thrombopathy
• Uremia, liver disease, macroglobulinemia
• NSAIDS, ASA
 Prolonged APPT

• Mixing studies
• Corrected mix
– Factor assays VIII, IX, X, XI XII
– Liver function
– Vit K
• Non corrected mix
– Lupus anticoagulant
– Factor specific inhibitors
 Prolonged PT
• Mixing studies
• Corrected mix
– Factor assays VII
– Liver function tests
– Vit K
• Non corrected mix
– Factor specific inhibitors
– Lupus anticoagulant unlikely
 Drugs
• Antiplatelet agents
• Anticoagulants
• Drugs associated with thrombocytopenia
• Herbal medications
– Garlic
– Ginseng
– Ginko biloba
 Conditions not to miss
• Haemophilia A
• Haemophilia B
• Von Willebrands disease
• Deficiency of Factor VII, VIII, IX, X, XI
• Factor specific inhibitors
• Platelet dysfunction
• Hypofibrinoginemia/dysfribrinoginemia
 Preoperative Risk Management
• Phlebotomy to decrease hct < 45
• PRC transfusison to achieve Hb 10 g/dl
• Maintain plts > 50,000/ml
• Vit K /FFP/Prothrombin Complex (Cofact) to
achieve PT < 3 second kontrol
• Cryoprecipitate to achieve aPTT ratio <1.3
 Thrombopathy

• Correct underlying disorder

• Desmopressin acetate
Perioperative Management:
Blood Thinners

» When to stop
• Aspirin (general indication) 7 days
• Aspirin (TIA / CVA / MI) 7 days
• NSAIDS 3-7 days
• Cox II inhibitors --------
• Clopidogrel (Plavix) 4-7 days
• Persantine 7 days
• Coumadin variable
• Herbal remedies 14 days

(Gingko, Ginseng, Garlic, Feverfew)

Intraoperativ
 Intra-op Complications
• Infection
• Fluid volume excess or deficit
• Injury r/t positioning (review positions)
• Hypothermia
• Malignant hyperthermia
• Bleeding
 Bleeding intra operative
• Laboratory finding
– Test of coagulatio system :
• aPTT, PT and platelet count
• aPTT ­ àintrinsic coagulation deficiency
• PT­ à extrinsic coagulation deficiency
 Bleeding intra operative
• Management
– Active bleeding without obvious surgical
sources of bleeding, platelet count less than
50.000/mm3
– Treatment : FFP and Platelets
-Eeach unit thrombocyte increases count by
5-10k
Postoperative Assessment
Approach to Post-operative bleeding

1. Is the bleeding local or due to a hemostatic failure?

§ Local: Single site of bleeding usually rapid with

minimal coagulation test abnormalities

§ Hemostatic failure: Multiple site or unusual pattern

with abnormal coagulation tests
 Management of
postoperative complications
•Postoperative Haemorrhage
•Causes
• inadequate operative haemostasis
• a technical mishap as slipped ligature
•Management
• re-operation to stop bleeding
• some preparation is necessary
 Indication for wound exploration
• Bleeding at the rate of 10 ml/kg/hour in the first
hour after operation à blood is sent for aPTT, PT,
and platelet count
• Persistent bleeding > 5ml/kg/hour for each of the
next three hours or
• bleeding that total 20 ml/kg/hour in the first four
hour after operation

•(Edmund AJ, Hemost Thromb 5th, 1103-1119.2006)

 Post operative management
• Bleeding after operation :
– Test of coagulation : PT, aPTT, platelet count
and fibrinogen
– Treatment :
• PT ­ à Th/ FFP
• fibrinogen < 100 mg/%---> Cryprecipitate
• Platelet <100.000/ml à Th/ platelet transfusion
• Suspected fibrinolysis: EACA, tranexamid acid
• PT, aPTT, platelet normal à Th/ FFP and EACA,
tranexamic acid
Practice Guidelines for component therapy in Massive
Blood Loss

• FFP:if APTT,INR >1.5 x normal

– 2 or more units of FFP
– 10 -15 mL/kg

• Platelets: Platelet count < 50 - 100 x10*9/L

– if platelets < 100 then 1platelet pool
– if platelets <50 then 2 platelet pools

• Cryoprecipitate: Fibrinogen < 1.0 g/L

– 10 units cryoprecipate
 Perioperative management of
patients on long term oral AC

• Weigh the risk of thromboembolism against the

risk of bleeding
• Who are most at risk if OAT is interrupted?
• Mechanical heart valves
• Atrial fibrillation
• Prior stroke or multiple risk factors
• Recent(<1 month) DVT
Pharmacological techniques/agents

• Antifibrinolytic agents
– Aprotinin
– tranexamic acid
– EACA (epsilon-aminocaproic acid)
• Desmospressin (DDAVP)
• Fibrin sealants
• rVIIa (NovoSeven)
 Approach to bleeding disorders
Summary
• Identify and correct any specific defect of hemostasis
– Laboratory testing is always needed to establish the cause of
bleeding
– Screening tests (PT,PTT, platelet count) will often allow placement
into one of the broad categories
– Specialized testing is usually necessary to establish a specific
diagnosis
• Use non-transfusional drugs whenever possible
• RBC transfusions for surgical procedures or large
blood loss
 Approach to thrombosis risk
• Identify and correct any thrombosis risk
– Risk of thrombosis
– History of thrombosis

• Using anticoagulans
AC regimens for Chronic OAT patient
undergoing non cardiac surgery
Clinical Situation
Procedures associated with low
bleeding risk (dental, cataract and
dermatologic)
Aortic valve prosthesis and no
additional risk factors or A. fib with operate when INR <1.5; resume
a low stroke risk
MV or AV with multiple risk
factors; recent VTE(<3 months);
AF and high stroke risk
Anticoagulation regimen
Continue OAT at usual dose or
target INR to =2
Stop OAT 4-5 days pre surgery,
daily dose of warfarin on the day of
surgery
Stop OAT 3-5 days prior to surgery;
start IV heparin when INR <2; stop
heparin 6 hrs prior to surgery;
restart sq heparin and oral AC as
soon as possible; Stop heparin
when INR therapeutic for 2
consecutive days.
 DVT Prophylaxis guidelines
Drug Abdominal Total Hip Total Knee Medical
Surgery Replacement Replacement Conditions
Unfract- 5000 U 5000 U
ionated SC q8-12 SC q8-12
Heparin

Warfarin Start post Start post 1 mg PO qd

operation operation for
Target INR Target INR indwelling
2-3 2-3 catheters

Enoxaparin 40 mg SC qd
30 mg SC 30 mg SC
40 mg SC q12h, 1st dose q12h, 1st dose
qd, 1st dose 12-24 h post 12-24 h post op
1-2 hrs op or 40 mg
preop SC qd starting
12h preop
 DVT Prophylaxis guide (Continued)
Drug Abdominal Total Hip Total Knee Medical
Surgery Replacement Replacement Conditions

Dalteparin 2500 IU SC 2500 IU SC q24h,

q24h, preop 2h preop and 6h
(Moderate postop then 5000
risk) or 5000 IU SC
IU SC q24, 1st q24(Moderate risk)
dose q8-12h or 5000 IU SC q8-
preop (High 12h, then q24h
risk Patients) postop (High risk
Patients)
 DVT Prophylaxis guide (Continued)
Drug Abdominal Total Hip Total Knee Medical
Surgery Replacement Replacement Conditions

Fonda- 2.5 mg SC 6 h 2.5 mg SC 6 h

parinux postop, then postop, then
2.5 mg SC qd 2.5 mg SC qd
•Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

 •
Thromboembolic risk categories

Thromboembolic
Risk
Bridging

High
•YES
Moderate

Low •NO

• •Douketis, Blood 2011

 •Perioperative Management

•Bleeding risk •Thrombotic risk

•Stop •Bridging
•antithrombotics
 •
Bridging

Thromboembolic
Risk
Bridging

High LMWH therapeutic

LMWH therapeutic
Moderate
LMWH low dose

Low none

• •Douketis, Blood 2011

 •Discontinuation of VKA
•PREOPERATIVE MANAGEMENT
•Stop •Stop
•THROMBOPROPHYLAXIS
•warfarin •acenocoumarol

• NO VKA
•Days •-6 -5 -4 -3 -2 -1 0P

•Check INR
•if < 1.5: surgery possible

•Check INR
•if >2.0: 6-10 mg vit. K p.o.

•Check INR
•if >2.0 (>2.5): check daily
•if <2.0 (<2.5): LMWH (except low thrombotic risk)
•Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h
before surgery
 •Discontinuation of VKA
•POSTOPERATIVE MANAGEMENT
•THERAPEUTIC •LMWH DOSE

•PROPHYLACTIC
•High/moderate
•STOP LMWH
THROMBOTIC RISK
•IF INR >2.0

•RESUME VKA

•DAYS •0P +1 +2 +3 +4 +5 +6

• RESUME VKA

•Low
•THROMBOTIC RISK

•STOP LMWH
•USUAL THROMBOPROPHYLAXIS •IF INR >2.0
•DOAC and perioperative management

Low bleeding risk

• Do not stop DOAC

• Perform intervention at trough level
• OD dosing: halt morning dose until after
intervention
• BID dosing: miss morning dose
•Anticoagulation and perioperative management

Practical advice

• Do not stop VKA too early

• Last therapeutic dose of LMWH 24 h
before surgery
• Resume therapeutic LMWH not before 48
h postop.
 •Heparin bridging – bleeding risk

All patients Heart valves AFIB

N=224 N=112 N=112

Major bleeding 15 (6.7%) 8 (7.1%) 7 (6.3%)

intraoperative 8 (3.6%) 4 (3.6%) 4 (3.6%)

<7 T postop. 5 (2.2%) 4 (3.6%) 1 (0.9%)
•Kovacs, Circulation 2004

Low High All patients

bleeding risk bleeding risk N=650
N=542 N=108

Major bleeding 0.74% 1.85% 0.92%

•Douketis, Arch Intern Med 2004
•Direct oral anticoagulants – perioperative management

Practical advice
• Prescribe DOAC exactly as licensed
• Check contraindications
• Dose according to indication an renal function
• check renal function and ensure proper diuresis
• Collect standardized bleeding and thrombotic history
• Lower dose in case of higher bleeding risk
• Use platelet function inhibitors together with DOAC with caution
• Avoid long acting NSARs
• No preoperative heparin bridging
 •Low bleeding risk
•Dabigatran,
Apixaban
•day - 3 •day - 2 •day - 1 •day 0 •day + 1 •day + 2 •day + 3

•Rivaroxaban

•day - 3 •day - 2 •day - 1 •day 0 •day + 1 •day + 2 •day + 3

•P R E O P E R A T I V E •P O S T O P E R A T I V E
•Dabigatran – perioperative management
•Elective
surgery/interventions

Last intake before surgery

Renal function
Half life
(CrCl in ml/min)
High bleeding risk
Standard risk
or major surgery

≥ 80 ~ 13 h >48 h >24 h

≥ 50 to < 80 ~ 15 h >72 h >36 h

≥ 30 to < 50 ~ 18 h >96 h >48 h

•EHRA guidelines, Heidbuchel, Eur Heart J 2013

 Perioperative Management

•D i r e c t or a •OP
l anticoagulants

•Stop •Start
 •Rivaroxaban, Apixaban – perioperative
management
•Elective
surgery/interventions
Last intake before surgery
Renal function
(CrCl in ml/min)
High bleeding risk or
Standard risk
major surgery

≥ 80 >48 h >24 h

≥ 50 to < 80 >48 h >24 h

≥ 30 to < 50 >48 h >24 h

≥ 15 to < 30 >48 h >36 h

•EHRA guidelines, Heidbuchel, Eur Heart J 2013

•Rivaroxaban – perioperative management
•High bleeding risk

•day -3 •day-2•day -1 •day 0 •day+1•day+2•day+3

•P R E O P E R A T I V E •P O S T O P E R A T I V E
•usual thromboprophylaxis
•Direct oral anticoagulants

Restart after surgery

• Not licensed for postoperative thromboprophylaxis
except for elective hip/knee replacement.
• Immediate and complete hemostasis à resume
DOAC after 6-8 hours.
• Maximum concentration within 2-3 h.
• Start therapeutic dose not before 48-72 h postop.
• Use LMWH at prophylactic dose until safe to use
therapeutic dose.
• Thank You
•RE-ly – dabigatran in atrial fibrillation

Periprocedural bleeding
100
D110
90 20
D150
80 Warfarin
15
70
•% Cases

60 10

50
5
40
30 0
minor major reoperation transfusion

20
10
0
minor major reoperation transfusion

•Healey, Circulation 2012

•RE-ly – dabigatran in atrial fibrillation

Periprocedural thromboembolism
100
D110
90
D150
80 1
Warfarin
70 0.8
•% Cases

60
0.6
50
0.4
40
0.2
30
20 0
CV death stroke
10
0
CV death stroke

•Healey, Circulation 2012