Anticoagulation in the Geriatric Surgical Patient - #10
Take QuizReview perioperative anticoagulation management of geriatric patients.
Considerations
- Patient’s bleeding risk: bleeding history is most important factor. Includes history of excessive bleeding (menorrhagia, hematuria, epistaxis, purpura or petechiae, etc.), coagulopathies, family history of coagulopathies, anticoagulation meds, and coagulation labs such as PT/INR.(3)
- Patient’s risk of thromboembolism: Most important factor is personal history of venous thromboembolism or DVT/PE. Also consider conditions such as atrial fibrillation, coronary artery disease, diabetes mellitus, hypertension, peripheral vascular disease, heart failure, valvular disease, or the presence of mechanical valves. Also hypercoagulable states such as Factor V Leiden, protein C&S deficiency, etc.(3)
- Risk of operative procedure: Consider location of surgery, extent of surgery, and ability to control potential bleeds through compression, etc. (3)
Management of Patients with Oral Anticoagulation.(4,5)
| Annual Risk of Thromboembolism | Management |
|---|---|
| Low (<4%) such as atrial fibrillation with no history of stroke | Withhold anticoagulation for 4 days prior to surgery, resume full dose postoperatively |
| Moderate (4-7%) such as mechanical aortic valve | Withhold anticoagulation for 4 days prior to surgery, optional to use IV heparin or subcutaneous LMWH when INR subtherapeutic. Resume warfarin post-operatively. |
| High (>7%) such as atrial fibrillation with history of stroke | Withhold anticoagulation for 4 days prior to surgery, optional to use IV heparin or subcutaneous LMWH when INR subtherapeutic, but discontinue prior to surgery. Resume warfarin post-operatively. |
Geriatric patient in a perioperative hospital setting.
Patient undergoing invasive procedure currently taking warfarin for history of thromboembolism.
Warfarin use in patients over age 65 reached 12.8% in 2006. Among all patients hospitalized, 9.3% of warfarin users died compared with 4.8% of those not on warfarin1. Among trauma patients, those on warfarin preinjury were 3.1 times more likely to die.(2)
1. List 3 considerations in perioperative anticoagulation management of geriatrics patients.
2. Give examples of low, moderate, and high risk thromboembolic states/conditions.
3. Explain general anticoagulation perioperative management for each level of risk.
Review of Systems (ROS)
Geriatric Topics
ACGME Compentencies
Science Principles
- Dossett LA, et al. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Archives of Surgery. 146(5):565-70, May 2011. http://www.ncbi.nlm.nih.gov/pubmed/?term=prevalence+and+implications+of+preinjury+warfarin+use
- Bonville DJ, et al. Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery. 150(4):861-8, Oct 2011 http://www.ncbi.nlm.nih.gov/pubmed/22000201
- Heit JA, et al. Perioperative management of the chronically anticoagulated patient. Journal of Thrombolysis. 12:81-7. 2001. http://www.ncbi.nlm.nih.gov/pubmed/11711693
- Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Internal Med. 163(8):901-8. Apr 2003. http://www.ncbi.nlm.nih.gov/pubmed/12719198
- Jafri S. Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy. Am Heart Journal. 147(1): 1-15. 2004. http://www.ncbi.nlm.nih.gov/pubmed/14691412
- Guyton AC, Hall JE. Textbook of Medical Physiology. St. Louis, MO: Saunders. 11th Edition. 2005.
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