Anticoagulation

1. Peri-operative
anticoagulation
Dr. Mustafa Bayoumi
“Clinical fellow in trauma and
orthopedics- ST1”
Dr. Wong
Orthogeriatric consultant

2. What is thrombosis?

3.  Thrombosis is the formation of a blood clot,
known as a thrombus, within a blood vessel. It
prevents blood from flowing normally through
the circulatory system.

4. IS thrombosis bad?

6. Leading cause of death in
western countries

7.  what stops you from bleeding when you hurt
yourself?
 In a healthy body, blood clots play an important
role in this. At the site of a cut, blood platelets and
red blood cells are held together by a rope-like
molecule called fibrin. This forms a blood clot,
which plugs up the cut and stops bleeding. This is
an important process.
 it can, however; cause major health issues when it
happens at the wrong time.


8.  When a blood clot forms in the veins, it is
known as venous thromboembolism. This
can cause deep vein thrombosis and
pulmonary embolisms. When a clot forms
in the arteries, it is called
atherothrombosis, which can lead to heart
attack and stroke.

9.  DVT… where?

11.  Varicose viens??

13. Paget-Schroetter Syndrome
(PSS)

14.  It's a rare kind of DVT that typically happens
to a young, healthy person who plays sports
that use the upper arms a lot, like swimming
and baseball. The vein can get squeezed by
the muscles around it. This pressure, along
with repeated movements, can cause a clot in
your shoulder. Symptoms like swelling, chest
pain, and a blue color to your skin may come
on suddenly. PSS can be serious if it's not
treated right away.

15. Who needs Anticoagulation

17. AF
stroke
prevention
Deep vein
thrombosis
Pulmonary
embolism
Artificial
heart
valves
Post
surgical?
temporary

18. CHAD score vs chad vasc?

20.  What is the has bled score?
 HAS-BLED is a scoring system developed to
assess 1-year risk of major bleeding in
patients taking anticoagulants with atrial
fibrillation. ... Major bleeding is defined as
being intracranial bleedings, hospitalization,
hemoglobin decrease > 2 g/dL, and/or
transfusion

22. Procedural bleeding risk
Low / major bleed risk
1.5%
Diagnostic procedure eg endoscopy,
angiography
Dental procedures
Minor ortho surgeries: hands/ feet/
shoulder
High Major risk >1.5
Body cavity surgery eg
intracrania/spinal/ocular
>45 mins surgeries are major surgeries
Urological/ laprascopic surgeries
Surgery in highly vascular organ

25.  What's factor I
What's factor 2?
Factor 6 ?
Factor 4 ?

27. How Do we anticoagulate?

32. Q/ a situation where heparin wont
be effective?

33.  Child with nephrotic syndrome?.. Losing anti
thrombin enzyme
you would actually give them heparin plus
FFP to get heparin a substance to act on and
therefore be effective

34. The Warfarin

35.  https://www.youtube.com/watch?v=nBnIwB66
7XY&t=72s

36.  NB:
warfarin inhibits 1972 +proties C & S
Protien C is anticoagulant
Warfarin acts as a pro-coagulant initially?
 Need for heparin on initation ttt with VKA

37.  Warfarin initial action as a procoagulant can
lead to warfarin induced skin necrosis

38.  Hirudin derived direct thrombin inhibitors
 Dabigtran
 argatroban

41. the Xa’s… NOAC’s
 Rivaroxaoban
 Edoxaban
etc…

45. VIT k as an antidote?? .. All or
non effect in terms of reversing
warfarin effect.
Hard to titrae? /VIT k overdose..
Some one with a heart valve?
Thrombosis/ procoagulant state

46. FFP on the other hand allows you
to” gradually sneak your way up? In
terms of homeostasis instead of all
or non effect .. Aka “slamming the
door”

47.  Protamine.. Positively charged molecule that
attracts heparin ( large molecule with negative
charge)

48. Noacs causing major bleeding..?

50.  What anticoagulation Cancer patients should
be on?

51. Contraindications to Noac?

54. Bridging guildines
 MMG086
 Periprocedural (perioperative) management of
already anticoagulated patients

55.  https://www.webmd.com/dvt/ss/slideshow-
thrombosis-types

56. Topic to read on
 How to treat some one with major bleeding
and is on NOACs?

57. Questions?

58. Factors that contribute to
increased risk of VTE while
flying/travelling
Higher risk
of venous
thrombo-
embolism
Prolonged
immobilization
Cramped
sitting position
Dehydration
Low cabin
humidity/ low
oxygen

59. All elective surgeries?
Elective
surgeries
with higher
VTE risk
General
anathesia
lasting > 30
minutes
Operations that
lead to
significant
immobility
Vascular
disruptions
incluind the
use of a
tourniquet
Cancer or
suspected
cancer patients

60. Pre operative
Operative
Post operative

61. Flying after high risk elective
surgeries : time frame
<4 weeks (or <3
months in LL
orthopedic surgeries)
• Significant high risk
of developing VTE
• Advise against
flying/ if unavoidable
VTE prevention as
per NICE guidelines
4-8 weeks post
surgery
• Slightly high risk
• VTE prevention as
per NICE guidelines
>8 weeks
• Low risk of VTE
• General advise (
detailed later)

62. Moderate-Major lower limb
surgeries = Higher risk
1
• Major joint arthroplasty
2
• Ankle fusion
3
• Tendon reconstruction

63. Coach or car journey > 6
hours = Long flight in Aeroplanes
for 4 hours or more

64. Avoid prolonged
immobility
Maintain normal
fluid intake
Avoid excessive
alchol as it leads to
dehydration and
inertia
Wear appropriate
compression
stockings unless
contraindictaed
To seek urgent
medical advice if
you develop swollen
painful legs or SOB

65. General advice for the patients
post operatively to
prevent VTE

66. Unavoidable surgery following
a prolonged flight?
 Well’s score can help doctors assess a patient's
risk for VTE especially if presenting for
emergency / or elective surgery right after a
flight over 4 hours within the preceding 4
weeks.
 Or even presenting after 3-4 hours flights
within the preceding two weeks.
 The score can aid in the decision whether to
postpone the surgery or to carry on with it

68. Flights > 4 hours
Score0
surgery to be
delayed for at least
2 weeks post flight .
If unavoidable,
then:
1-Compression
stocking for 4 weeks
+/- pharmacological
thrombo-prophylaxis
if immobile at home
Score1
surgery to be
delayed for at least
2 weeks post flight .
If unavoidable then:
1- compression
stockings for 6
weeks post
operatively
2-If there is
immobility at home
pharmacological
thrombo-prophylaxis
Score>2
surgery to be
delayed for at least
4 weeks post flight.
If unavoidable then:
1- compression
stockings for 6
weeks post
operatively
2-Discuss with a
hemtaologist
pharmacological
thrombo-prophylaxis

69. Special considerations
Withold the pill
until six weeks
after surgery
To be offered/
advised on
alternative
contraceptive
measures.
OCOCP
Bridging
anticoagulation
to be discussed
with hematology
Long term
anticoagulation

70. If travelling is unavoidable
Moderate
risk patients
General advice on DVT
prevention
Use of well fitted
graduated compression
stockings/obtain
adequate medical
travel insurance before
travelling.
High risk
patients
As for moderate risk
patients
Seek specialist advice
from a hematologist
regarding whether the
use of LMWH is
indicated.

71.  https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C6326126/

72.  Aspirin
 There is good evidence that aspirin is useful in preventing
arterial thrombosis, but it is not recommended for the
prevention of venous thrombosis during travel. Aspirin does
not reduce VTE in high risk patients [11, 17]. Furthermore a
Cochrane review noted that approximately one patient in 40
taking low dose aspirin develop gastric irritation [18].
 Due to insufficient evidence supporting the use of aspirin in
travel related venous thrombosis, guidelines from the
American College of Chest Physicians recommend against
its use for VTE prevention associated with travel [6]. UK
guidelines support the view that aspirin should not be used
for the prevention of VTE in hospital patients [7] or travellers
[8].

73. https://www.cochranelibrary.com/
cdsr/doi/10.1002/14651858.CD00
4002.pub3/full
 Authors' conclusions
 There is high‐quality evidence that airline passengers similar to
those in this review can expect a substantial reduction in the
incidence of symptomless DVT and low‐quality evidence that leg
oedema is reduced if they wear compression stockings. Quality
was limited by the way that oedema was measured. There is
moderate‐quality evidence that superficial vein thrombosis may
be reduced if passengers wear compression stockings. We
cannot assess the effect of wearing stockings on death,
pulmonary embolism or symptomatic DVT because no such
events occurred in these trials. Randomised trials to assess
these outcomes would need to include a very large number of
people.

74.  The risk of venous thromboembolism (VTE)
for most travellers is low. For a flight > 4
hours, in healthy individuals, the risk is
estimated to be 1 in 6,000. The risk increases
with longer duration of travel and with multiple
flights within a short period. The risk of
pulmonary embolism is much lower.

75. https://www.ncbi.nlm.nih.gov/pmc
/articles/PMC6272050/
 7. Conclusion
 Clinical data on VTE prophylaxis for travel-related
VTE are still rather limited. Physicians must
balance between risks of thrombosis and bleeding
in an individual patient. Consideration on the
patient’s risk score and traveling schedule is
helpful. Current clinical trial data suggest that
DOACs can be used to treat travel-related VTE.
Although the direct clinical data for primary
prophylaxis is lacking, there is no rationale to
suggest that DOACs are not effective in this
indication.