warfarin and Blood-Loss--Surgical

Interruption of chronic anticoagulation due to the bleeding risk associated with an elective procedure may also lead to an elevated risk of thromboembolism. Periprocedural bridging with either unfractionated heparin or low-molecular weight heparin had been the mainstay of therapy for many patients receiving chronic warfarin treatment based on an estimation of a patient's thromboembolic risk. However, recent results from cohort studies and placebo-controlled randomized trials in the periprocedural use of heparin bridging for warfarin-treated patients reveal a consistent two- to three-fold increase in the risk of major bleeding and no benefit in terms of a reduction in the risk of stroke and systemic embolism. The most recent antithrombotic guidance statements suggest that the majority of patients on chronic warfarin, except those at high risk of thromboembolism, may safely interrupt and resume warfarin without heparin bridging in elective periprocedural settings. In addition, data from the use of heparin bridging in patients on direct oral anticoagulants during temporary interruption for an elective procedure also reveal harm and no benefits of this approach. A strategy that considers the pharmacokinetic properties of the direct oral anticoagulants, the bleeding risk of each procedure, and patient renal function would safely obviate the need for heparin bridging. In this review, the authors summarize the major studies of heparin bridging for patients on chronic oral anticoagulants that may lead to a change in practice in periprocedural antithrombotic management and define an evidence-based heparin bridging protocol for those patient groups who may be the candidates for this approach.

Topics: Administration, Oral; Anticoagulants; Blood Loss, Surgical; Elective Surgical Procedures; Heparin, Low-Molecular-Weight; Humans; Kidney Function Tests; Perioperative Care; Risk Factors; Thromboembolism; Warfarin

This review article examines updates to the literature during the past 5 years on numerous topics which were felt to have ongoing controversy. These topics include venous thromboprophylaxis, tranexamic acid usage, tourniquet usage, and wound closure techniques.. For each individual topic, a literature search was conducted on several databases with emphasis on studies that were published in the past 5 years. Preference was given to meta-analyses and randomized controlled trials.. Tranexamic acid is a safe and effective treatment modality, and consideration should be given to use multiple doses and combine different modes of administration. Certain treatment modalities (skin sutures, limited or no tourniquet usage) can cause greater patient satisfaction at a cost of longer operating times. Postoperative anticoagulation is still a very controversial topic. There is however some evidence suggesting prolonging anticoagulation to 35 days postoperative.. By analyzing the results of the aforementioned studies, surgeons can implement the most up-to-date evidence-based care when doing total knee arthroplasty surgery. However, many of these selected topics continue to have a component of ongoing controversy with no definitive conclusions developed in recent literature.

Topics: Anticoagulants; Antifibrinolytic Agents; Arthroplasty, Replacement, Knee; Aspirin; Blood Loss, Surgical; Factor Xa Inhibitors; Heparin; Heparin, Low-Molecular-Weight; Humans; Platelet Aggregation Inhibitors; Tourniquets; Tranexamic Acid; Venous Thromboembolism; Warfarin; Wound Closure Techniques

Atrial fibrillation patients often require warfarin interruption for an invasive procedure or surgery. Heparin bridging therapy has been frequently used during warfarin interruption under the premise of providing a theoretical mitigation against thromboembolism that overweighs expected higher rates of bleeding. Up until recently, little definite clinical evidence was available to guide the hospitalist on optimal perioperative anticoagulant management. The landmark BRIDGE (Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation) trial provided high-quality evidence that a simple interruption of warfarin in the average atrial fibrillation patient undergoing an elective procedure or surgery is noninferior to bridging therapy for efficacy and superior to bridging therapy in preventing major bleeding. To guide the hospitalist, we propose a treatment algorithm based on these recent data. We review the literature that led to the trial and highlight its practice-changing implications as a proof of concept that calls to question the premise of heparin bridging therapy beyond the atrial fibrillation population. Journal of Hospital Medicine 2016;11:652-657. © 2016 Society of Hospital Medicine.

Topics: Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Heparin, Low-Molecular-Weight; Hospitalists; Humans; Perioperative Care; Randomized Controlled Trials as Topic; Risk Factors; Thromboembolism; Treatment Outcome; Warfarin

To compare the safetyand efficacy of warfarin treatment continuation and heparin-bridging therapy during cardiac rhythm device (CRD) implantation in patients chronically treated with anticoagulants.We performed a search and analysis of peer-reviewed studies Four randomized controlled trials (RCTs)were included in our analysis with 941 patients. The bleeding risk in patients continuing warfarin perioperatively was lower than those interrupting warfarin and using a heparin-bridge (RD -0.08, 95% CI -0.17 to 0.02, p< 0.05). There was no significant difference in ischaemic risk between two methods (RD 0, 95% CI -0.01 to 0.02, p=1.00). Hence, in patients undergoing long-term warfarin therapy, continuation of warfarin treatment is a safe and efficacious perioperative strategy for during CRD implantations, while interruption of warfarin with a heparin bridge may increase the bleeding risk in these patients.

Topics: Anticoagulants; Blood Loss, Surgical; Hematoma; Heparin; Humans; Pacemaker, Artificial; Perioperative Care; Postoperative Hemorrhage; Prosthesis Implantation; Randomized Controlled Trials as Topic; Warfarin

Oral anticoagulation is a widely used treatment and atrial fibrillation (AF) is the most frequent indication. We review the therapeutic options on an important clinical challenge: rapid reversal anticoagulation in the setting of an urgent invasive procedure. We report a case of a 71-year-old man treated with warfarin who was over-anticoagulated when presented to the emergency department for syncope due to severe bradiarrhythmia and needed temporary pacing. Intravenous infusion of vitamin-k was not adequate for rapid reversal over anticoagulation whereas the administration of a Prothrombin Complex Concentrate (PCC) was able to quickly reverse anticoagulant activity and allowed the performance of an urgent invasive procedure without hemorrhagic complication. The aim of this paper is to draw attention to possible therapeutic strategies to reduce the risk of bleeding related to over-anticoagulation with vitamin-K antagonists (VKAs) in case of urgent invasive procedure, emphasizing the role of PCC in keeping with national and international guidelines.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation Factors; Blood Loss, Surgical; Humans; Male; Pacemaker, Artificial; Vitamin K; Warfarin

Anticoagulants can complicate the approach to the management of patients undergoing operative interventions. We review new anticoagulants that have been introduced recently to the market or that are undergoing investigations for treatment of nonvalvular atrial fibrillation and venous thromboembolism prophylaxis: Dabigatran, rivaroxaban, apixiban, and edoxaban.

Topics: Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Blood Loss, Surgical; Clinical Trials as Topic; Dabigatran; Humans; Morpholines; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Stroke; Surgical Procedures, Operative; Thiazoles; Thiophenes; Venous Thromboembolism; Warfarin

A number of novel oral anticoagulants that directly target factor Xa or thrombin have been developed in recent years. Rivaroxaban and apixaban (direct factor Xa inhibitors) and dabigatran etexilate (a direct thrombin inhibitor) have shown considerable promise in large-scale, randomised clinical studies for the management of thromboembolic disorders, and have been approved for clinical use in specific indications. Rivaroxaban is licensed for the prevention of venous thromboembolism in patients undergoing elective hip or knee replacement surgery, the treatment of deep-vein thrombosis and prevention of recurrent venous thromboembolism, and for stroke prevention in patients with non-valvular atrial fibrillation. Based on the clinical trial data for rivaroxaban, feedback on its use in clinical practice and the authors' experience with the use of rivaroxaban, practical guidance for the use of rivaroxaban in special patient populations and specific clinical situations is provided. Although most recommendations are in line with the European summary of product characteristics for the approved indications, additional and, in several areas, different recommendations are given based on review of the literature and the authors' clinical experience.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Blood Loss, Surgical; Clinical Trials as Topic; Dabigatran; Factor Xa Inhibitors; Female; Humans; Male; Morpholines; Practice Guidelines as Topic; Pregnancy; Rivaroxaban; Stroke; Thiophenes; Venous Thromboembolism; Venous Thrombosis; Warfarin

Perioperative management of patients on chronic anticoagulant use involves balancing individual risk for thromboembolism and bleeding. Discontinuation of antithrombotic therapy can place patients at increased risk of thromboembolic complications, whereas continuing antithrombotic therapy can increase procedure-related bleeding risk. Temporary perioperative substitution of low-molecular weight heparin or unfractionated heparin in place of warfarin, "the bridge therapy" is often used in the periprocedural period, but the indications and timing of this is still uncertain. This review addresses the risk stratification of patients according to thromboembolic risk, indications, timing, and duration, and a practical approach to bridge therapy.

Topics: Anticoagulants; Blood Loss, Surgical; Heparin; Humans; Perioperative Care; Postoperative Hemorrhage; Risk Assessment; Thromboembolism; Warfarin

The purpose of this article is to review the effective options for the reversal of vitamin K antagonists (warfarin and it coumarin analogues) and to help identify the option best suited for the patient requiring urgent surgery.. Vitamin K antagonists, the mainstay in long-term anticoagulation therapy, can be reversed with the administration of vitamin K, frozen plasma (FP), recombinant factor VIIa (rFVIIa), or the recently approved four-factor prothrombin complex concentrate (PCC), Octaplex. While there is little evidence to suggest a superiority of PCC over FP, the availability of PCC in Canada is an important therapeutic addition requiring a thorough understanding of its pharmacology and risk benefit profile for the reversal of vitamin K antagonists. The use of PCC in the management of microvascular bleeding should be limited to very specific indications and should not be indicated in the routine management of massive blood loss.. In order to limit the blood loss associated with surgery and the management of uncontrolled bleeding, PCC is an important addition to our therapeutic armamentarium in the reversal of vitamin K antagonists.

Topics: Animals; Anticoagulants; Antidotes; Antifibrinolytic Agents; Blood Coagulation Factors; Blood Loss, Surgical; Coumarins; Hemorrhage; Humans; Vitamin K; Warfarin

Patients undergoing oral anticoagulation treatment with vitamin K antagonist (VKA) therapy are at a high risk of bleeding when undergoing an invasive surgery or procedure. Bridging therapy with parenteral heparin, usually at therapeutic doses, aims to protect these patients against thromboembolism during temporary periprocedural interruption of VKA therapy. Whether or not to interrupt VKA therapy and initiate bridging therapy is a difficult decision that is based upon both the patient's and the procedure's thromboembolic and bleeding risks.. There are minor procedures that can safely be done without the need for VKA interruption. Patient groups that may benefit from bridging therapy during temporary VKA interruption for a procedure include those who are at moderate-to-high risk of thromboembolism. Procedural bleed risk should determine when to resume bridging and VKA therapies. Recent findings highlight that low-molecular-weight heparin, usually in the outpatient setting, is the preferred agent over intravenous unfractionated heparin for bridging therapy, which includes patients with prosthetic heart valve indications for VKA therapy.. Large, recently initiated placebo-controlled trials in bridging therapy are discussed, as well as future alternatives to VKA therapy in oral anticoagulation during the periprocedural period.

Topics: Administration, Oral; Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Heparin, Low-Molecular-Weight; Humans; Preoperative Care; Vitamin K; Warfarin

Patients at high risk of arterial or venous thromboembolic events often receive chronic treatment with long-term oral anticoagulants such as warfarin. However, if these patients require an invasive procedure, they may require a temporary interruption of their warfarin therapy to minimize their bleeding risk during the procedure. As warfarin has a long half-life and an unpredictable pharmacokinetic profile, short-acting parenteral anticoagulants, such as unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH), may be of benefit in protecting the patient from thromboemboli while their warfarin dose is withheld. Such "bridging therapy" has traditionally been provided in-hospital with intravenous UFH; however, recent data have suggested that LMWH may be an effective alternative, with potential cost-savings due to the ability to provide bridging therapy in the outpatient setting.

Topics: Anticoagulants; Blood Loss, Surgical; Cost-Benefit Analysis; Drug Administration Schedule; Drug Costs; Heparin; Heparin, Low-Molecular-Weight; Hospital Costs; Humans; Length of Stay; Postoperative Hemorrhage; Risk Assessment; Stroke; Thromboembolism; Warfarin

Many patients who are on long-term antithrombotic therapy (e.g. warfarin and/or antiplatelet agents) must be assessed for temporary discontinuation for a procedure or surgery, making this a salient topic for the hospitalist physician. Discontinuation of antithromhotic therapy can place patients at increased risk of thromboembolic complications while continuing antithrombotic therapy can increase procedure-related bleeding risk. Bridging anticoagulation with heparin or low molecular weight heparins is often used in the periprocedural period, but a great deal of uncertainty exists about how and when to use bridging anticoagulation. Because there is very little Level 1 evidence to define optimal care, both clinical practice and expert consensus guideline opinions vary. For the hospitalist, it is of critical importance to understand the available data, controversies, and management options in order to approach patient care rationally. This review provides a step-wise literature-based discussion addressing the following four questions: (1) What is the optimal management of antiplatelet therapy in the periprocedural period? (2) Are there very low bleeding risk procedures that do not require interruption of oral anticoagulation? (3) Are there low thromboembolic risk populations who do not require periprocedural bridging? (4) How do you manage patients who must discontinue anti-coagulants but are at an increased thrombotic risk?

Topics: Aspirin; Blood Loss, Surgical; Drug-Eluting Stents; Fibrinolytic Agents; Heparin; Hospitalists; Humans; Preoperative Period; Risk Factors; Thromboembolism; Warfarin

The management of patients who require temporary interruption of warfarin therapy because of elective surgery or another invasive procedures is clinically important because of the increasing prevalence of patients who are receiving warfarin and the availability of low-molecular-weight heparins, which facilitate out-of-hospital perioperative anticoagulation. The two main issues that need to be considered in perioperative anticoagulant management is the patient's risk of a thromboembolic event when warfarin therapy is interrupted and the risk of bleeding that is associated with the surgery or procedure. An assessment of these factors will determine the optimal perioperative anticoagulant management approach. The overall objective of this review is to provide a practical approach relating to perioperative anticoagulation which can be used in everyday clinical practice.

Topics: Blood Loss, Surgical; Fibrinolytic Agents; Humans; Perioperative Care; Risk Assessment; Thromboembolism; Treatment Outcome; Warfarin

Clinicians, including anesthesiologists, surgeons, and intensivists, are frequently called on to correct coagulopathy in patients receiving oral anticoagulation therapy. Before elective surgery, anticoagulation reversal may be undertaken over several days by discontinuing warfarin or vitamin K treatment, but rapid correction is required in an emergency. European and American guidelines recommend prothrombin complex concentrates (PCCs) for anticoagulation reversal in patients with life-threatening bleeding and an increased international normalized ratio. Compared with human fresh frozen plasma, PCCs provide quicker correction of the international normalized ratio and improved bleeding control. Although there are historic concerns regarding potential infectious and thrombotic risks with PCCs, current PCC formulations are much improved. Recombinant activated factor VII is a potential alternative to PCCs, but preclinical comparisons suggest that PCCs are more effective in correcting coagulopathy. Although many patients who require rapid reversal of warfarin are currently treated with fresh frozen plasma, PCCs should be considered as an alternative therapy.

Topics: Blood Coagulation; Blood Coagulation Factors; Blood Loss, Surgical; Disease Management; Hemostatics; Humans; International Normalized Ratio; Perioperative Care; Vitamin K; Warfarin

The objectives of this study were to review perioperative bridging strategies for anticoagulated patients and to describe a novel bridging strategy for tonsillectomy in an anticoagulated patient that addresses both primary and secondary hemorrhage risks.. A literature review and a case report are presented. PubMed was reviewed for evidence-based recommendations on perioperative management of anticoagulated patients. A case report is detailed of a 28-year-old woman with antiphospholipid syndrome on warfarin for high risk of venous thrombosis who underwent tonsillectomy. A perioperative bridging strategy incorporating outpatient low-molecular weight heparin and inpatient unfractionated heparin was implemented to minimize risks of thrombosis and primary and secondary posttonsillectomy hemorrhage.. Limited evidence supports a consensus on the best perioperative management of anticoagulated patients. Tonsillectomy in an anticoagulated patient has not been described previously. The patient in this case underwent successful tonsillectomy with no thrombosis or bleeding after 1 month of follow-up.. Tonsillectomy can be done relatively safely in an anticoagulated patient at high risk for thrombosis. The perioperative bridging strategy should account for its unique risk of primary and secondary postoperative hemorrhage. A proposed algorithm for managing these competing risks is presented.

Topics: Adult; Algorithms; Anticoagulants; Antiphospholipid Syndrome; Blood Loss, Surgical; Dose-Response Relationship, Drug; Drug Administration Schedule; Enoxaparin; Evidence-Based Medicine; Female; Heparin; Heparin, Low-Molecular-Weight; Humans; Long-Term Care; Perioperative Care; Peritonsillar Abscess; Postoperative Hemorrhage; Risk Factors; Tonsillectomy; Venous Thrombosis; Warfarin

The use of blood thinners has increased dramatically in recent years among the general, and especially among the elderly, population. When these patients need to undergo cutaneous surgery, the surgeon encounters the obvious problem of whether to stop these medications before surgery.. The objective was to evaluate the risks and benefits associated with the continuation of blood thinners perioperatively in cutaneous and Mohs micrographic surgery.. The study comprises two parts: a search of the literature in English that examined articles that related to the perioperative use of blood thinners in dermatologic surgery and a presentation of data of continuous warfarin therapy in patients who underwent Mohs surgery in our practice.. A total of 15 articles were published in the literature until October 2003. One article showed an increase in complications in patients treated with warfarin, but not with aspirin. All other articles showed no increase in complications during the perioperative period. Data from our practice showed that of a total of 2790 patients, 68 were operated on while taking warfarin (2.4%). Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients.. Continuous treatment with blood thinners perioperatively in patients undergoing Mohs and cutaneous surgery is not associated with an increase in surgical complications. Discontinuation of these medications may increase the risk of cerebral and cardiovascular complications.

Topics: Anticoagulants; Aspirin; Blood Loss, Surgical; Humans; Intraoperative Care; Intraoperative Complications; Mohs Surgery; Practice Guidelines as Topic; Risk Assessment; Skin Neoplasms; Warfarin

Patients receiving chronic anticoagulation therapy pose a clinical challenge when therapy needs to be interrupted for surgical or invasive procedures. Maintaining anticoagulation places them at risk of serious bleeding complications, whereas discontinuing anticoagulation puts them at risk of thromboembolic complications. The main patient groups that may require a periprocedural alternative to oral anticoagulation include patients with prosthetic heart valves, atrial fibrillation, and hypercoagulable states and those with chronic venous thrombosis undergoing surgery. Currently, there is little consensus on appropriate perioperative management of patients on long-term warfarin therapy. This article is an attempt to bring together all the available data on periprocedural bridging to assess the available options for patients undergoing surgical procedures and to provide a rationale for using low-molecular-weight heparins (LMWHs) while individualizing the risks versus benefits in a given patient population.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Heart Valve Prosthesis; Humans; International Normalized Ratio; Middle Aged; Postoperative Hemorrhage; Risk; Risk Factors; Thromboembolism; Thrombosis; Time Factors; Warfarin

An increasing number of patients who require surgical treatment for skin tumours also take anticoagulants or anti-platelet drugs to prevent thromboembolic events. Stopping therapy places the patient at risk from a thromboembolic event, whilst continuing treatment places them at risk from bleeding complications during surgery. We have reviewed all of the published studies of the effects of warfarin, aspirin, non-steroidal anti-inflammatory and other anti-platelet drugs on surgical outcome in patients having skin surgical procedures. There is little evidence that continuing with treatment is harmful in any of these groups with the exception of warfarin therapy, where the risk of haemorrhagic complications is presumably dependent on the degree of anticoagulation.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Blood Loss, Surgical; Dermatologic Surgical Procedures; Humans; Platelet Aggregation Inhibitors; Warfarin

The management of patients who require temporary interruption of oral anticoagulant therapy because of surgery or other invasive procedures is a clinically important topic because of the increasing prevalence of patients who are receiving oral anticoagulants and the availability of low-molecular-weight heparins (LMWHs), which allow out-of-hospital perioperative anticoagulation. The optimal management of such patients has been hampered by the lack of well-designed prospective studies investigating the efficacy and safety of different perioperative management strategies. The two main issues that need to be considered in perioperative anticoagulant management is the patient's risk of thromboembolic event when anticoagulant therapy is interrupted and the risk of bleeding that is associated with the surgery or procedure. An assessment of these factors will determine the perioperative management approach. The objectives of this review are to focus on practical issues relating to perioperative anticoagulation and the implementation of a perioperative anticoagulation management approach that can be used in everyday clinical practice.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Female; Heart Valve Prosthesis; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Middle Aged; Perioperative Care; Postoperative Hemorrhage; Renal Insufficiency; Risk Factors; Thromboembolism; Thrombosis; Venous Thrombosis; Warfarin

Patients maintained on warfarin for atrial fibrillation, mechanical heart valves, or deep venous thrombosis may occasionally need to stop their anticoagulation during invasive procedures. This article reviews the literature on bleeding risks of certain procedures, thrombosis risks of stopping anticoagulation, and heparin and warfarin pharmacokinetics. Recommendations regarding how to manage anticoagulated patients are discussed.

Topics: Anticoagulants; Blood Loss, Surgical; Heart Valve Prosthesis; Heparin; Humans; International Normalized Ratio; Perioperative Care; Risk Factors; Stroke; Thrombosis; Warfarin

When the need for surgery arises, temporary interruption of long-term anticoagulation exposes patients to additional thrombotic risk. There is no consensus as to how perioperative anticoagulation should be managed in this setting. Based on an individual assessment of risk factors for arterial or venous thromboembolism and the risk of postoperative bleeding, this review outlines an approach to the perioperative management of anticoagulation that is designed to optimize patient safety and efficient delivery of health care. The duration of interruption of oral anticoagulation is minimized by withholding four daily doses of warfarin before surgery, and by restarting warfarin the same day that surgery is performed. This will usually achieve satisfactory coagulation status intraoperatively (e.g., International Normalized Ratio of 1.5 or less) with a low risk of postoperative bleeding. Supplemental prophylaxis with therapeutic doses of heparin, usually unfractionated heparin, can be reserved for patients with the highest risk of thromboembolism. In the preoperative period, this applies to patients who have had an episode of arterial or venous thromboembolism in the preceding month. In the postoperative period, this approach is generally reserved for patients with an episode of venous thromboembolism in the preceding 3 months, and patients with an episode of arterial embolism in the preceding month who have a low risk of bleeding. Differences in the approach to management of anticoagulation before and after surgery relate to the fact that surgery is an important risk factor for venous, but not arterial, thromboembolism, and that recent surgery greatly increases the risk of anticoagulant-induced bleeding. Subcutaneous unfractionated or low-molecular-weight heparin, in doses recommended to prevent venous thromboembolism in high-risk surgical patients, should be administered to in-patients who have a lesser risk of thromboembolism until oral anticoagulation is reestablished.

Topics: Anticoagulants; Blood Loss, Surgical; Heparin; Heparin, Low-Molecular-Weight; Humans; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Blood Loss, Surgical; Chronic Disease; Endoscopy; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Rhinitis; Sinusitis; Warfarin

The study was designed to evaluate the effect of warfarin on perioperative transfusion, bleeding and coagulation status in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).. There were controversy about the effect of warfarin on perioperative transfusion and bleeding.. Medical records from 107 consecutive patients with atrial fibrillation (AF) on warfarin therapy undergoing cardiac surgery with cardiopulmonary bypass (CPB) from 2008 to 2013 at a single university teaching hospital were retrospectively reviewed to compare the patients on to those not on warfarin therapy in terms of perioperative transfusion requirement, postoperative 24-h bleeding amount, and coagulation status assessment using prothrombin time (PT), international normalised ratio (INR) and rotational thromboelastometry (ROTEM®).. Although PT/INR was significantly prolonged both before and after surgery in patients on warfarin therapy, ROTEM® data, perioperative transfusion requirement and postoperative 24-h bleeding amount (785 ± 331 vs 676 ± 303 mL, P = 0·089, respectively) were not significantly different between the patients on and those not on warfarin therapy.. In patients on warfarin therapy undergoing cardiac surgery with CPB, warfarin therapy did not significantly increase perioperative transfusion requirement and bleeding.

Topics: Adult; Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Cardiopulmonary Bypass; Female; Humans; Male; Middle Aged; Perioperative Care; Retrospective Studies; Warfarin

The bleeding risk after cold snare polypectomy in anticoagulated patients is not known.. To compare the bleeding risk after cold snare polypectomy or conventional polypectomy for small colorectal polyps in anticoagulated patients.. Prospective randomized controlled study.. Municipal hospital in Japan.. Anticoagulated patients with colorectal polyps up to 10 mm in diameter were enrolled. Patients were randomized to polypectomy with either cold snare technique (Cold group) or conventional polypectomy (Conventional group) without discontinuation of warfarin. The primary outcome measure was delayed bleeding (ie, requiring endoscopic intervention within 2 weeks after polypectomy). Secondary outcome measures were immediate bleeding and retrieval rate of colorectal polyps.. Seventy patients were randomized (159 polyps): Cold group (n = 35, 78 polyps) and Conventional group (n = 35; 81 polyps). The patients' demographic characteristics including international normalized ratio and the number, size, and shape of polyps removed were similar between the 2 techniques. Immediate bleeding during the procedure was more common with conventional polypectomy (23% [8/35]) compared with cold polypectomy (5.7% [2/35]) (P = .042). No delayed bleeding occurred in the Cold group, whereas 5 patients (14%) required endoscopic hemostasis in the Conventional group (P = .027). Complete polyp retrieval rates were identical (94% [73/78] vs 93% [75/81]). The presence of histologically demonstrated injured arteries in the submucosal layer with cold snare was significantly less than with conventional snare (22% vs 39%, P = .023).. Small sample size, single-center study.. Delayed bleeding requiring hemostasis occurred significantly less commonly after cold snare polypectomy than conventional polypectomy despite continuation of anticoagulants. Cold snare polypectomy is preferred for removal of small colorectal polyps in anticoagulated patients. (. NCT 01553565.).

Topics: Adenoma; Aged; Aged, 80 and over; Anticoagulants; Arteries; Blood Loss, Surgical; Colon; Colonic Polyps; Colonoscopy; Colorectal Neoplasms; Female; Hemostasis, Endoscopic; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Hemorrhage; Rectum; Vascular System Injuries; Warfarin

Dabigatran reduces ischemic stroke in comparison with warfarin; however, given the lack of antidote, there is concern that it might increase bleeding when surgery or invasive procedures are required.. The current analysis was undertaken to compare the periprocedural bleeding risk of patients in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial treated with dabigatran and warfarin. Bleeding rates were evaluated from 7 days before until 30 days after invasive procedures, considering only the first procedure for each patient. A total of 4591 patients underwent at least 1 invasive procedure: 24.7% of patients received dabigatran 110 mg, 25.4% received dabigatran 150 mg, and 25.9% received warfarin, P=0.34. Procedures included: pacemaker/defibrillator insertion (10.3%), dental procedures (10.0%), diagnostic procedures (10.0%), cataract removal (9.3%), colonoscopy (8.6%), and joint replacement (6.2%). Among patients assigned to either dabigatran dose, the last dose of study drug was given 49 (35-85) hours before the procedure on comparison with 114 (87-144) hours in patients receiving warfarin, P<0.001. There was no significant difference in the rates of periprocedural major bleeding between patients receiving dabigatran 110 mg (3.8%) or dabigatran 150 mg (5.1%) or warfarin (4.6%); dabigatran 110 mg versus warfarin: relative risk, 0.83; 95% CI, 0.59 to 1.17; P=0.28; dabigatran 150 mg versus warfarin: relative risk, 1.09; 95% CI, 0.80 to 1.49; P=0.58. Among patients having urgent surgery, major bleeding occurred in 17.8% with dabigatran 110 mg, 17.7% with dabigatran 150 mg, and 21.6% with warfarin: dabigatran 110 mg; relative risk, 0.82; 95% CI, 0.48 to 1.41; P=0.47; dabigatran 150 mg: relative risk, 0.82; 95% CI, 0.50 to 1.35; P=0.44.. Dabigatran and warfarin were associated with similar rates of periprocedural bleeding, including patients having urgent surgery. Dabigatran facilitated a shorter interruption of oral anticoagulation.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00262600.

Topics: Aged; Aged, 80 and over; Anticoagulants; Benzimidazoles; beta-Alanine; Blood Loss, Surgical; Brain Ischemia; Cardiac Pacing, Artificial; Cataract Extraction; Dabigatran; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Risk Factors; Stroke; Thromboembolism; Warfarin

Peri-procedural management of warfarin reflects an intricate balance between the restoration of haemostasis and appropriate thromboprophylaxis. This prospective single-arm study assessed the safety and efficacy of a convenient schedule, incorporating low-dose intravenous vitamin K (vitK(IV) ) for short-term warfarin reversal prior to elective surgery, as well as vitK-dependent factor levels (vitK-Factors) and International Normalized Ratio (INR) pre- and post-vitK(IV) . One seventy eight patients on long-term warfarin received 3mg vitK(IV) 12-18 h pre-procedure with no adverse reactions. 167/178 (94%) achieved an INR≤1·5 post-vitK(IV) on the day of surgery, while all achieved INR≤1·7. Four patients had procedure-associated major bleeding, but importantly had achieved a pre-procedure INR<1·5 and vitK-Factors >0·30iu/ml. No patient suffered a symptomatic thromboembolism during the 6-week follow-up. Median days to re-establish a therapeutic INR were 4 (range 2-11). VitK(IV) near normalized all vitK-Factors, with a uniform pattern of depletion and repletion in association with an increase and decrease in INR, respectively; and from the data, INR<1·5 correlated with vitK-Factors >0·30iu/ml. Low-dose vitK(IV) for short-term warfarin reversal was reliable and safe, and successfully lowered the INR to an acceptable level for planned surgery, with no excess of bleeding, thromboembolism, delayed discharge, or resistance to warfarin. The protocol was simple and convenient for both the patients and the healthcare institution.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Drug-Related Side Effects and Adverse Reactions; Elective Surgical Procedures; Female; Humans; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Premedication; Preoperative Care; Treatment Outcome; Vitamin K; Warfarin

Replacement of warfarin with heparin for dental extractions in patients on long-term warfarin therapy is associated with wasted time, consumed labor, and increased treatment expenses. The aim of this study was to evaluate the safety of dental extraction without altering the warfarin regimen in patients with an international normalized ratio from 1 to 4.. Forty patients who underwent tooth extraction were divided into 4 groups: continuation of warfarin without interruption (group 1), warfarin bridged with low-molecular-weight heparin (group 2), warfarin bridged with unfractionated heparin (group 3), and a control group of healthy individuals (group 4). Total amount of bleeding (milligrams) was measured for 20 minutes after tooth extraction. International normalized ratio values on the operative day and number of extra gauze swabs used for bleeding control in the first 48 hours were recorded for each patient. Results were statistically analyzed by analysis of variance, Fisher least-significant difference post hoc test, Pearson correlation, χ(2) test, and Student t test.. Mean amounts of bleeding were 2,486 ± 1,408; 999 ± 425; 1,288 ± 982; and 1,736 ± 876 mg for groups 1, 2, 3, and 4, respectively. There was no severe postoperative bleeding in any patient and the number of used extra gauze swabs did not differ significantly among groups.. With the aid of local hemostatic agents, dental extraction in patients receiving warfarin who have an international normalized ratio from 1 to 4 could be carried out without a significant risk of bleeding and without altering the anticoagulant regimen.

Topics: Adult; Aged; Analysis of Variance; Anticoagulants; Blood Loss, Surgical; Chi-Square Distribution; Dental Care for Chronically Ill; Endpoint Determination; Female; Heart Valve Prosthesis; Hemostatic Techniques; Heparin; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Male; Middle Aged; Statistics, Nonparametric; Tooth Extraction; Warfarin

Temporary interruption of anticoagulation therapy is usually recommended for anticoagulated patients undergoing invasive procedures to minimize their bleeding risks. We validated the current consensus recommendation on warfarin interruption which were based on Western population studies to determine if they could safely be applied to Asians. The international normalized ratios (INR) in twenty warfarinised patients with a stable INR of 2-3 were prospectively measured at days 0, 3 and 5 after stopping warfarin for procedures or at completion of treatment. The median INR at days 0, 3 and 5 were 2.30 (95% CI 2.16-2.43), 1.32 (95% CI 1.22-1.57) and 1.06 (95% CI 1.05-1.13) respectively (P < 0.001 for trend). All patients were below therapeutic INRs by day 3 with 14 patients (70%, 95% CI 49.92-90.08) achieving INR readings below 1.5. By day 5, all INRs were below 1.5 and only 2 patients (10%, 95% CI -3.15 to 23.15) had INRs above 1.2. There were no significant peri-procedure bleeding or thrombotic events in the 1 month following interruption of warfarin. Our results suggest that the current international recommendation of stopping warfarin for 5 days prior to procedure can safely be applied to Asians without compromising risk of bleeding or thrombosis.

Topics: Aged; Asian People; Blood Loss, Surgical; Female; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Practice Guidelines as Topic; Thrombosis; Time Factors; Warfarin

High variability in drug response and a narrow therapeutic index complicate warfarin therapy initiation. No existing algorithm provides recommendations on refining the initial warfarin dose based on genetic variables, clinical data, and international normalized ratio (INR) values. Our goal was to develop such an algorithm. We studied 92 patients undergoing primary or revision total hip or knee replacement. From each patient we collected a blood sample, clinical variables, current medications, and preoperative and postoperative laboratory values. We genotyped for polymorphisms in the cytochrome P450 (CYP) 2C9 and vitamin K epoxide reductase (VKORC1) genes. Using stepwise regression, we developed a model for refining the warfarin dose after the third warfarin dose. The algorithm explained four fifths of the variability in therapeutic dose (R(2)(adj) of 79%). Significant (P > .05) predictors were INR value after 3 doses (47% reduction per 0.25-unit rise), first warfarin dose (+7% per 1 mg), CYP2C9*3 and CYP2C9*2 genotype (-38% and -17% per allele), estimated blood loss (interacting with INR(3)), smoking status (+20% in current smokers), and VKORC1 (-11% per copy of haplotype A). If validated, this model should provide a safer, more effective process for initiating warfarin therapy.

Topics: Adult; Aged; Aged, 80 and over; Algorithms; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aryl Hydrocarbon Hydroxylases; Blood Loss, Surgical; Cytochrome P-450 CYP2C9; Female; Genetic Variation; Genotype; Humans; International Normalized Ratio; Male; Middle Aged; Mixed Function Oxygenases; Prospective Studies; Vitamin K Epoxide Reductases; Warfarin

When warfarin is interrupted for surgery, low-molecular-weight heparin is often used as bridging therapy. However, this practice has never been evaluated in a large prospective study. This study was designed to assess the efficacy and safety of bridging therapy with low-molecular-weight heparin initiated out of hospital.. This was a prospective, multicenter, single-arm cohort study of patients at high risk of arterial embolism (prosthetic valves and atrial fibrillation with a major risk factor). Warfarin was held for 5 days preoperatively. Low-molecular-weight heparin was given 3 days preoperatively and at least 4 days postoperatively. Patients were followed up for 3 months for thromboembolism and bleeding. Eleven Canadian tertiary care academic centers participated; 224 patients were enrolled. Eight patients (3.6%; 95% CI, 1.8 to 6.9) had an episode of thromboembolism, of which 2 (0.9%; 95% CI, 0.2 to 3.2) were judged to be due to cardioembolism. Of these 8 episodes of thromboembolism, 6 occurred in patients who had warfarin deferred or withdrawn because of bleeding. There were 15 episodes of major bleeding (6.7%; 95% CI, 4.1 to 10.8): 8 occurred intraoperatively or early postoperatively before low-molecular-weight heparin was restarted, 5 occurred in the first postoperative week after low-molecular-weight heparin was restarted, and 2 occurred well after low-molecular-weight heparin was stopped. There were no deaths.. Bridging therapy with subcutaneous low-molecular-weight heparin is feasible; however, the optimal approach for the management of patients who require temporary interruption of warfarin to have invasive procedures is uncertain.

Topics: Anticoagulants; Arterial Occlusive Diseases; Aspirin; Atrial Fibrillation; Blood Loss, Surgical; Cohort Studies; Dalteparin; Elective Surgical Procedures; Feasibility Studies; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Complications; Postoperative Complications; Postoperative Hemorrhage; Premedication; Preoperative Care; Prospective Studies; Risk; Thromboembolism; Treatment Outcome; Vitamin K; Warfarin

Our goal was to evaluate the local hemostatic effect of n-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) glue in warfarin-treated patients who undergo outpatient oral surgery without a change in their level of anticoagulation.. Thirty consecutive warfarin-treated patients randomly assigned to study and control groups and 10 patients who had never been on anticoagulant therapy serving as the negative control group were included in this trial. Before multiple teeth extractions, all patients had a prothrombin time and the international normalized ratio (INR) determined. To gain hemostasis and primary closure, gelatin sponge and multiple interrupted resorbable sutures were used in the control and negative control groups, and Histoacryl glue and the minimal number of interrupted resorbable sutures were used in the study group. Postoperatively, patients were to contact the oral surgeon if abnormal bleeding occurred. Patients who did not have postoperative bleeding were seen on the 10th postoperative day. Data were collected, and statistical differences in age and gender distributions, number of teeth extracted, INR levels, and bleeding that required treatment were analyzed with the Mantel-Haenzel test. Statistical significance was defined as a value of P <.05.. Local hemostasis was obtained immediately in study patients and only after 10 to 20 minutes in the control and negative control patients. In relation to bleeding complications, there were no cases of postoperative bleeding requiring treatment in both the negative control patients and study patients. In the control patients, 5 cases had postoperative spontaneous bleeding that required treatment. This difference was statistically significant. No patient had wound infection and the healing process appeared to be normal.. Multiple extractions can be performed in patients taking oral anticoagulant therapy without a change in their level of anticoagulation provided an efficient local hemostatic measure is instituted. And, in this regard, Histoacryl glue, used as a topical adhesive over approximated wound edges, is an effective and easily applicable local hemostatic for oral surgery in such patients.

Topics: Aged; Ambulatory Surgical Procedures; Anticoagulants; Blood Loss, Surgical; Dental Care for Chronically Ill; Drug Interactions; Enbucrilate; Female; Fibrin Tissue Adhesive; Gelatin Sponge, Absorbable; Hemostatics; Humans; Male; Middle Aged; Oral Hemorrhage; Oral Surgical Procedures; Polypharmacy; Postoperative Hemorrhage; Tooth Extraction; Treatment Outcome; Warfarin

The aim of this prospective study was to compare the effectiveness of a 4.8% tranexamic acid mouthwash versus an autologous fibrin glue preparation to control hemostasis in patients therapeutically anticoagulated with warfarin who required dental extractions without interruption of their treatment.. The 49 patients who underwent 152 dental extractions were randomly allocated to 2 groups: Group A were required to rinse with 10 mL of a 4.8% tranexamic acid solution 4 times a day for 7 days postoperatively. Group B received autologous fibrin glue intraoperatively. The international normalized ratio was measured on the day of the procedure. All procedures were performed on an ambulatory basis by the same surgeon.. Of the 49 patients, 2 presented with postoperative bleeding (4%). Both patients were from the autologous fibrin glue group and were found to have grossly elevated international normalized ratios on the day of the bleeding that was unaccounted for.. This study supports the consensus that dental extractions can be performed without modification of oral anticoagulant treatment. Local hemostasis with an absorbable oxidized cellulose mesh, tranexamic acid, and sutures is the more cost efficient of the 2 methods compared; however, autologous fibrin glue has an important role in patients unable to use a mouthwash effectively.

Topics: Adult; Aged; Anticoagulants; Blood Loss, Surgical; Dental Care for Chronically Ill; Drug Interactions; Female; Fibrin Tissue Adhesive; Hemostatics; Humans; Male; Middle Aged; Mouthwashes; Oral Hemorrhage; Oral Surgical Procedures; Polypharmacy; Postoperative Hemorrhage; Prospective Studies; Tooth Extraction; Tranexamic Acid; Treatment Outcome; Warfarin

One mg daily warfarin was compared to variable dose warfarin (PT 1.3-1.5 times the normal PT), as prophylaxis against deep vein thrombosis (DVT) following unilateral hip replacement for degenerative joint disease (DJD). Ninety-eight patients entered onto study after having had negative color Doppler ultrasounds of the legs. Patients receiving 1 mg began therapy 7 days preoperatively and continued daily until discharge. Patients receiving the variable dose took 5 mg the night preoperatively, and thereafter daily based upon the daily PT. Seventy-eight patients completed the study protocol. No patient completing the protocol had DVT or pulmonary embolus (PE). Based upon intent to treat for all registered patients, one from each group had DVT after withdrawal from study. For patients receiving 1 mg warfarin daily, PTs extended none or slightly. Therefore, 1 mg warfarin can be used to prevent postoperative DVT following elective hip surgery.

Topics: Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Dose-Response Relationship, Drug; Female; Humans; Male; Middle Aged; Prothrombin Time; Treatment Outcome; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Warfarin

Orgaran (danaparoid sodium injection) is a novel antithrombotic agent. Early studies suggest that this compound may be beneficial in preventing deep vein thrombosis in predisposed patients. This multicenter, randomized, assessor blinded, clinical trial compared subcutaneous danaparoid with warfarin for the prevention of deep vein thrombosis in patients undergoing hip replacement surgery. Bilateral venography was used to detect thrombi. Patients also underwent follow-up examinations 1, 2, and 3 months after discontinuation of the study to determine the after effects of treatment. Nearly 27% of patients who received warfarin and 14.6% of patients who received danaparoid developed deep vein thrombosis, a risk reduction of 46%. The absolute difference in the incidence of deep vein thrombosis was 12.3% in favor of danaparoid. The incidence of venographically documented proximal deep vein thrombosis was 1.5% for danaparoid and 4.1% for warfarin. These results demonstrate that danaparoid is more effective than warfarin in preventing deep vein thrombosis following hip replacement surgery. The preoperative administration of danaparoid does not increase surgical blood loss compared with warfarin.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Chondroitin Sulfates; Dermatan Sulfate; Drug Combinations; Female; Heparitin Sulfate; Humans; Male; Middle Aged; Postoperative Complications; Single-Blind Method; Treatment Outcome; Venous Thrombosis; Warfarin

The effectiveness and safety of warfarin were compared with those of a low-molecular-weight heparin (dalteparin) for the prevention of deep-vein thrombosis after total hip arthroplasty in a prospective, randomized, multi-institutional trial. Patients who were older than eighteen years of age and were scheduled to have an elective primary or revision total hip arthroplasty were eligible; 580 patients were randomized, 550 had the operation and received prophylaxis, and 382 had evaluable venograms. Prophylaxis was provided either with warfarin beginning the night before the operation or with dalteparin beginning two hours before the operation and was continued until venography was performed. Bleeding was assessed on the basis of intraoperative blood loss, transfusion requirements, a decrease in hematocrit, and clinically identified bleeding complications. The prevalence of deep-vein thrombosis was found to be significantly lower in the patients who had received dalteparin than in those who had received warfarin (twenty-eight [15 per cent] of 192 patients compared with forty-nine [26 per cent] of 190 patients; p = 0.006). Deep-vein thrombosis occurred in the calf veins of twenty-one patients (11 per cent) who had received dalteparin and of forty-three patients (23 per cent) who had received warfarin; this difference was significant (p = 0.003). Proximal deep-vein thrombosis occurred in ten patients (5 per cent) who had received dalteparin and in sixteen patients (8 per cent) who had received warfarin; however, with the numbers available, no significant difference could be detected (p = 0.185). We also could not detect a significant difference with regard to the intraoperative and postoperative blood loss, the decrease in hematocrit, and the prevalence of major bleeding complications between the two groups; however, the patients who had received dalteparin had a significantly higher prevalence of bleeding complications involving the operative site (p = 0.03), and a significantly greater percentage required postoperative transfusions (p = 0.001). We concluded that preoperative prophylaxis with dalteparin is significantly more effective than that with warfarin in preventing deep-vein thrombosis after total hip arthroplasty. The greater effectiveness of dalteparin must be considered, however, in light of an increased need for postoperative transfusions and an increase in the prevalence of wound-related bleeding complications.

Topics: Anticoagulants; Blood Loss, Surgical; Dalteparin; Female; Hemorrhage; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Premedication; Prospective Studies; Thrombophlebitis; Warfarin

We performed a prospective, randomized, double-blind trial of topical aprotinin versus placebo in 100 patients undergoing cardiac operations with cardiopulmonary bypass. Fifty-five patients received aprotinin. Forty underwent coronary artery bypass grafting (CABG) and 15 valve replacement +/- CABG. Of 45 patients in the control group 38 underwent CABG and 7 valve replacement +/- CABG. Aprotinin (50 mL; 70 mg) or placebo was applied topically to the heart, pericardium, and mediastinum before sternal closure. There were five reentries for bleeding with a surgical site identified in four. Mean blood loss was significantly less in the aprotinin group (653 versus 903 mL; p = 0.002), and fewer aprotinin patients received blood as a volume expander (67.5% versus 88%; p = 0.03). In coronary patients alone when aspirin administration was continued until the day of operation there was no difference between treatment and placebo groups (768 versus 879 mL). When aspirin administration was discontinued 2 weeks before operation there was a significant difference (558 versus 884 mL; p = 0.016) as in the group overall. This provides the potential for intrapericardial instillation for patients with excessive postoperative bleeding.

Topics: Administration, Topical; Adult; Aged; Aged, 80 and over; Algorithms; Aortic Valve; Aprotinin; Aspirin; Blood Loss, Surgical; Cardiopulmonary Bypass; Coronary Artery Bypass; Double-Blind Method; Female; Heart Valve Prosthesis; Hemostasis, Surgical; Humans; Male; Middle Aged; Mitral Valve; Premedication; Prospective Studies; Warfarin

In a randomized, prospective trial, a low-molecular-weight heparinoid (Org 10172 [Lomoparan]) was compared with warfarin for efficacy and safety in preventing deep-vein thrombosis in 263 patients who had an operatively treated fracture of the hip. One group of patients received Org 10172 in a dose of 750 units subcutaneously every twelve hours until the ninth postoperative day; on the seventh postoperative day, warfarin was added to the regimen. The other group received only warfarin. Both drugs were begun preoperatively, immediately after the admission evaluation. In the patients who received warfarin, the desired prothrombin time was one and one-half times the control level. Deep-vein thrombosis was detected by 125I-fibrinogen scanning and impedance plethysmography and was confirmed by phlebography and compression ultrasonography. Deep-vein thrombosis was found in nine (7 per cent) of the 132 patients who received Org 10172 and in twenty-eight (21 per cent) of the 131 patients who received warfarin (p less than 0.001). Adverse reactions were not significantly different in the two groups. Major bleeding complications occurred in eight patients in the Org-10172 group, only four of whom were receiving the drug at the time of bleeding, and in five patients who were receiving warfarin (not significant). There was no difference in intraoperative loss of blood or in requirements for transfusion. We concluded that the low-molecular-weight heparinoid Org 10172 is a safe, convenient, effective antithrombotic agent for the prevention of venous thrombosis after an operation for fracture of the hip.

Topics: Aged; Aged, 80 and over; Blood Loss, Surgical; Chondroitin Sulfates; Dermatan Sulfate; Female; Glycosaminoglycans; Heparinoids; Heparitin Sulfate; Hip Fractures; Humans; Iodine Radioisotopes; Male; Middle Aged; Molecular Weight; Plethysmography; Postoperative Complications; Prevalence; Prospective Studies; Risk Factors; Thrombophlebitis; Warfarin

To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures.. Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses.. Two Level-1 trauma centers.. One thousand four hundred forty-two geriatric (ages 60-105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither.. Cephalomedullary nail fixation.. Blood transfusion and calculated blood loss.. More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1-1.9] in contrast with 0.76 (95% CI, 0.5-1.2) for warfarin and 0.67 (95% CI, 0.3-1.4) for DOACs.. Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Anticoagulants; Aspirin; Blood Loss, Surgical; Cohort Studies; Hip Fractures; Humans; Platelet Aggregation Inhibitors; Retrospective Studies; Warfarin

Hip fracture is common in the elderly, many of whom are on anticoagulation. However, data are limited on outcomes with anticoagulation reversal in patients undergoing hip fracture surgery.. Adults ≥60 years old on oral anticoagulation who underwent hip fracture surgery at 21 hospitals in Northern California from 2006 to 2016 were identified through electronic databases. Outcomes were compared among patients treated and untreated with anticoagulation reversal preoperatively.. Of 1984 patients on oral anticoagulation who underwent hip fracture surgery, 1943 (97.9%) were on warfarin and 41 (2.1%) were on direct oral anticoagulants. Reversal agents were administered to 1635 (82.4%). Compared to a watch-and-wait strategy, patients receiving reversal agents were more likely to be white, male, comorbid, and with higher admission and preoperative international normalized ratios (P <0.001 for all comparisons). No difference for 30-day mortality was detected between reversal vs non-reversal (7.8% vs 6.0%, respectively; hazard ratio [HR], 1.30 [95% confidence interval (CI), 0.82-2.07]). For secondary outcomes, reversal was associated with higher risk of delirium (8.6% vs 4.9%, risk ratio [RR], 1.77 [95% CI, 1.08-2.89]) and increased mean length of stay (6.4 vs 5.8 days, P <0.05). After adjustment, associations were no longer significant for delirium (RR 1.60, 95% CI, 0.97-2.65) or length of stay (mean difference 0.08, 95% CI, -0.55-0.71). No associations were detected between reversal and other secondary outcomes.. No significant associations were found between reversal agents and 30-day mortality or other outcomes in patients on oral anticoagulation who underwent hip fracture surgery. Further investigation is needed.

Topics: Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Anticoagulants; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Asian; Black or African American; Blood Coagulation Factors; Blood Loss, Surgical; Blood Transfusion; Cohort Studies; Delirium; Factor Xa Inhibitors; Female; Fracture Fixation, Internal; Hip Fractures; Hispanic or Latino; Humans; International Normalized Ratio; Length of Stay; Male; Mortality; Orthopedic Procedures; Plasma; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Proportional Hazards Models; Retrospective Studies; Sex Factors; Vitamin K; Warfarin; White People

It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.

Topics: Anticoagulants; Blood Loss, Surgical; Cross-Sectional Studies; Female; Health Knowledge, Attitudes, Practice; Health Personnel; Humans; Male; Middle Aged; Needs Assessment; Practice Patterns, Physicians'; Qatar; Surgical Procedures, Operative; Warfarin; Withholding Treatment

The aim of this study was to review our experience with patients having gynaecological surgeries while on long-term anticoagulation and to postulate a better guide for their perioperative management.. A retrospective review of all women on long-term warfarin who underwent gynaecological surgeries from January 2003 to December 2012. Data from medical records including operation reports and inpatient and outpatient charts were reviewed and analyzed.. Sixty-seven cases from 58 patients were identified. Twenty and 38 patients underwent major and minor gynaecological surgeries, respectively. The incidence of postoperative bleeding was higher after major surgery (4 cases, 20%) than after minor surgery (1 case, 2.1%; P = 0.025). All bleeding complications occurred between postoperative day 3 and day 10. Three patients, who had resumption of warfarin at a lower dose and slowly stepped up, had no bleeding complications. None of our patients developed venous thromboembolic complications. There was one mortality due to septic shock.. Patients on long-term anticoagulation have a trend of increased bleeding complications after major gynaecological surgeries than in minor gynaecological surgeries. We suggest that delaying resumption of warfarin at a lower dose may have a role in reducing the risk of postoperative bleeding without increasing the risk of venous thromboembolism.

Topics: Adult; Aged; Blood Loss, Surgical; Female; Gynecologic Surgical Procedures; Humans; Middle Aged; Perioperative Period; Postoperative Hemorrhage; Retrospective Studies; Thrombolytic Therapy; Venous Thromboembolism; Warfarin

Topics: Aged; Arrhythmias, Cardiac; Blood Loss, Surgical; Hip Fractures; Humans; Male; Perioperative Care; Risk Factors; Venous Thromboembolism; Warfarin

For warfarin-treated patients with atrial fibrillation (AF) at low thromboembolic risk, recent studies have shown harm associated with periprocedural bridging using low-molecular-weight heparin. Clinician surveys have indicated a preference toward excessive bridging, especially among noncardiologists; however, little is known about actual practice patterns in these patients. We performed a retrospective evaluation of bridging in the setting of gastrointestinal endoscopy. We identified 938 patients with AF on warfarin who underwent esophagogastroduodenoscopy or colonoscopy between 2012 and 2016 at a tertiary health center. Urgent, inpatient, or advanced endoscopic procedures were excluded. Clinical variables were abstracted using a predefined data dictionary. Values were expressed as means and compared using a t test or a chi-squared test as appropriate. Three hundred seventy-four patients met criteria for analysis. Twenty-five percent of these patients received bridging therapy, including 11% of patients with CHADS

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Cardiologists; Clinical Decision-Making; Colonoscopy; Deprescriptions; Drug Substitution; Endoscopy, Digestive System; Female; Gastroenterologists; Heparin, Low-Molecular-Weight; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Physicians, Primary Care; Postoperative Hemorrhage; Practice Patterns, Physicians'; Retrospective Studies; Stroke; Warfarin

Thrombotic disorders remain one of the leading causes of death in the Western world. Dabigatran appeared as an alternative to warfarin for anticoagulation in the treatment of atrial fibrillation (AF). The risk associated with bleeding due to its use has been documented in several randomized clinical trials, but no large study has examined in detail the risk of bleeding during dental extraction and other dental procedures involving bleeding.. To compare the intensity of bleeding in individuals taking dabigatran or vitamin K antagonist (warfarin) and undergoing dental procedures.. Prospective, single-center, controlled study with one single observer. Patients diagnosed with nonvalvular AF, on warfarin or dabigatran, cared for at a cardiology referral center, and requiring single or multiple dental extractions, were evaluated up to seven days post-extraction. The following outcomes were assessed: bleeding time between the beginning and the end of suture and complete hemostasis; bleeding before the procedure, after 24 hours, 48 hours, 7 days, during and after suture removal (late); p<0.05 was defined as of statistical relevance.. We evaluated 37 individuals, 25 in the warfarin group and 12 in the dabigatran group. Age, sex, weight, height, blood pressure, color, schooling, family income and comorbidities were similar between the two groups. Regarding bleeding after 24 hours of the procedure, no one in the dabigatran group had bleeding, whereas 32% in the warfarin group had documented bleeding (p = 0.028). The other variables analyzed did not differ between the groups.. This study suggests that, regarding dental extraction, there is no statistically significant difference in the intensity of bleeding of patients taking dabigatran as compared to those taking warfarin. Bleeding 24 hours after the procedure was less frequent among patients on dabigatran.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Bleeding Time; Blood Loss, Surgical; Dabigatran; Female; Humans; Male; Middle Aged; Prospective Studies; Reference Values; Risk Factors; Statistics, Nonparametric; Time Factors; Tooth Extraction; Treatment Outcome; Warfarin

To compare blood loss, delay of surgery, and short-term adverse events in (1) patients admitted on warfarin versus nonanticoagulated controls and (2) warfarin patients with day of surgery (DOS) international normalized ratio (INR) of 1.5 or greater versus below 1.5.. Retrospective cohort.. Academic Level I trauma center.. One hundred twenty four patients treated surgically for hip fractures including patients presenting on warfarin (n = 62) and matched controls (n = 62).. Cephalomedullary nailing (CMN), hemiarthroplasty, or total hip arthroplasty.. The primary outcome was transfusion rate. Secondary outcomes included calculated blood loss, 30-day complication rate, and hours from emergency department presentation to surgery.. There was no significant difference in blood transfusion rates between the warfarin and control groups (P = 0.86). Blood transfusion was required in 58.1% of patients in the warfarin group (48.3% of arthroplasties and 65.5% of CMNs) compared with 56.6% of controls (41.9% of arthroplasties and 73.3% of CMNs). There were also no significant differences in calculated blood loss or in complication rates. Patients on warfarin had significantly longer time to surgery (P < 0.01). Subanalysis of the warfarin group showed that patients with DOS INR at or above 1.5 had similar transfusion rates, blood loss, and complications compared with patients with INR below 1.5. Treatment with CMN was the only covariate that was found to be a significant independent predictor of transfusion on multivariable analysis (P = 0.048).. Patients with hip fractures admitted on warfarin seem to be at similar risk of transfusion or adverse events compared with nonanticoagulated patients. Awaiting normalization of INR delayed surgery without reducing bleeding or preventing complications. Within reason, surgeons may consider proceeding with surgery in patients with INR above 1.5 if patients are otherwise medically optimized. The upper limit above which surgery causes increased blood loss is currently unknown.. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Age Factors; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Blood Transfusion; Case-Control Studies; Female; Follow-Up Studies; Fracture Fixation, Intramedullary; Hemiarthroplasty; Hip Fractures; Humans; Injury Severity Score; International Normalized Ratio; Logistic Models; Male; Middle Aged; Multivariate Analysis; Retrospective Studies; Risk Assessment; Sex Factors; Statistics, Nonparametric; Tertiary Care Centers; Time-to-Treatment; Treatment Outcome; Warfarin

To analyze bleeding-related complications among patients on long-term anticoagulation (AC) undergoing ureteroscopy (URS). Current American Urological Association/International Consultation on Urological Diseases guidelines state that it is safe to continue AC in routine URS; however, these recommendations are based on small case series.. There were 4799 identified URS procedures performed at our institution between June 2009 and February 2016. Records were then retrospectively reviewed to confirm AC use and identify periprocedural complications. Anticoagulant agents evaluated included warfarin, enoxaparin, and non-vitamin K antagonists (ie, rivaroxaban, dabigatran, apibaxan). Patients were excluded if they were taking a concurrent antiplatelet (AP) agent or if additional non-URS procedures were performed.. Of the 4799 URS procedures, 272 (5.6%) were done on patients taking chronic AC. Of these, 193 (71%) held AC, 53 (19%) were bridged with enoxaparin, and 26 (10%) continued AC. The median age was 70.2 years and the majority of patients (64.2%) underwent a stone procedure with a stone-free rate of 73%. The overall bleeding-related complication rate was 8.1% whereas the significant bleeding-related event rate was 5.9%. Patients continuing AC had the highest significant bleeding-related event rate at 15.4% compared to 9% and 3% for those bridged with enoxaparin and those who held, respectively (P = .01).. Continuation or bridging of AC may increase the risk of perioperative bleeding. The risks and benefits of proceeding with URS on AC must be weighed carefully. Pending external validation, this information may be used for patient counseling and risk stratification.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Enoxaparin; Female; Humans; Male; Middle Aged; Postoperative Hemorrhage; Retrospective Studies; Ureteral Diseases; Ureteroscopy; Warfarin

To describe estimated blood loss (EBL) with surgical abortion ≤14 weeks' gestation in anticoagulated patients.. We invited 170 clinicians involved in a professional listserv to report cases when they performed a surgical abortion on a patient ≤14 weeks' gestation taking an anticoagulant. Clinicians reported EBL and bleeding-related complications (need for a blood transfusion, additional surgical procedures to treat bleeding). We contacted clinicians 30 days postprocedure to capture postoperative complications.. Clinicians reported 52 cases between February 2011 and October 2013. Thirty percent of patients (16/52) stopped the anticoagulant with adequate time for the effects to abate prior to surgery (6 h for heparin, 24 h for low-molecular-weight heparin, International Normalized Ratio ≤1.7 the day prior to surgery for warfarin), while 69% (36/52) continued the anticoagulant either at therapeutic (25/36) or subtherapeutic (16/36) doses. Seventy-eight percent (28/36) of patients who continued the anticoagulant had an EBL of 50 mL or less compared to 88% (14/16) of those who stopped the anticoagulant with adequate time for its effects to abate (p=.73). Bleeding-related complications occurred in four anticoagulated patients and none of the patients who discontinued anticoagulant therapy.. Continuation of anticoagulation for planned surgical abortion under 84 days does not appear to be associated with heavy bleeding.

Topics: Abortion, Induced; Adult; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Female; Gestational Age; Heparin; Heparin, Low-Molecular-Weight; Humans; Obstetric Surgical Procedures; Warfarin

Warfarin is widely used to perform catheter ablation for atrial fibrillation (AF). Heparin is usually administered during this procedure to prevent thromboembolic events, while protamine is used to reduce the incidence of bleeding complications. The purpose of this study was to investigate the influence of heparin and protamine administration on the effects of warfarin and its safety. The subjects included 226 AF patients (206 males, 54.9 ± 9.1 years, paroxysmal/persistent AF: 118/108) undergoing AF ablation with the discontinuation of warfarin administration over 2 days. Heparin was administered to achieve an activated clotting time (ACT) above 300 s during the procedure. Several parameters of the coagulation status, including the prothrombin time international normalized ratio (PT-INR) and ACT values, measured immediately before and after protamine infusion were compared. The mean value of PT-INR prior to ablation was 1.9 ± 0.6. At the end of the procedure, the mean ACT and PT-INR values were 348.0 ± 52.9 and 2.9 ± 0.7, respectively. Following the infusion of 30 mg of protamine, both the ACT and PT-INR values significantly decreased, to 159.6 ± 31.0 (p < 0.0001) and 1.6 ± 0.3 (p < 0.0001), respectively. No cases of symptomatic cerebral infarction were observed, although femoral hematomas developed in 17 (7.5 %) of the patients without further consequence. The concomitant use of heparin augments the effect of warfarin. Meanwhile, protamine administration immediately reverses both the ACT and PT-INR, indicating the applicability of protamine for AF ablation in patients under the mixed administration of heparin and warfarin.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Blood Coagulation Tests; Blood Loss, Surgical; Catheter Ablation; Drug Administration Schedule; Drug Monitoring; Female; Heparin; Heparin Antagonists; Humans; Male; Middle Aged; Postoperative Hemorrhage; Predictive Value of Tests; Protamines; Risk Factors; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Approximately 10% of chronically anticoagulated patients require an invasive procedure annually. One in 10 procedures is emergent and requires prompt anticoagulation reversal. The study objective is to determine the safety and efficacy of a 3 factor prothrombin complex concentrate (PCC) for periprocedural anticoagulation reversal.. Consecutive patients receiving 3 factor PCC for warfarin reversal for either urgent/emergent invasive procedures or major bleeding were analyzed. Primary endpoints included percent achieving INR <1.5, peri-operative major hemorrhage, thromboembolism and death during the 40day post-infusion period.. Between January 1, 2010-December 31, 2012, 52 patients were treated with PCC for pre-procedural warfarin reversal and 113 patients for major bleeding. Within the peri-procedure group, there were 24 intra-abdominal surgeries, 12 percutaneous interventions, 6 cardiothoracic surgeries, 5 orthopedic and 3 endoscopic procedures. INR values <1.5 were achieved in 51% at 2.5h post-infusion. Major bleeding (13%), thromboembolism (13%) and mortality rates (15%) were high. Within the major bleeding group, PCC therapy reversed INR values (<1.5) in 75% of patients within 4h. For this group, thromboembolism (21%) and mortality rates (16%) were likewise high. Post-PCC anticoagulation, reinitiated in 37%, had no impact on bleeding or thrombotic complications. Mortality rates were threefold higher for those patients not restarting warfarin therapy.. Although PCC therapy promptly and effectively reverses INR values for patients requiring urgent/emergent invasive procedure both thromboembolic and fatal complications are soberingly high and call for judicious use of these agents in these high risk populations.

Topics: Aged; Anticoagulants; Blood Coagulation; Blood Coagulation Factors; Blood Loss, Surgical; Coagulants; Female; Humans; International Normalized Ratio; Male; Retrospective Studies; Surgical Procedures, Operative; Thromboembolism; Warfarin

To describe surgical outcomes and perioperative complications in patients taking antiplatelet and anticoagulation medications while undergoing cochlear implantation.. Case series with chart review.. Two tertiary otologic referral center.. Forty-six adult patients (2005-2014) who underwent cochlear implantation while on perioperative antiplatelet and/or anticoagulation therapy without interruption. Outcomes included estimated intraoperative blood loss, perception of increased difficulty secondary to bleeding, and postoperative complications attributable to continuing anticoagulation or antiplatelet therapy.. The cases of 46 patients (mean age, 69.5 years; 30.2% female) were analyzed. Of these, 39 patients were taking aspirin, 10 warfarin, and 7 clopidogrel. Aside from 3 (6.5%) patients with postoperative bruising without hematoma and 1 patient (2.2%) who reported self-resolving oral cavity blood, no intraoperative or postoperative complications occurred in any patient that could be ascribed to antiplatelet or anticoagulant use.. These data demonstrate that the risk of perioperative complications from continued antiplatelet or anticoagulation therapy is low. For subjects who are at risk of major complications (eg, deep venous thrombosis, pulmonary embolism, myocardial infarction, cerebrovascular accident) from temporary medication cessation, continuing antiplatelet or anticoagulation therapy through the perioperative period is an appropriate strategy.

Topics: Aged; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Cochlear Implantation; Female; Hemorrhage; Humans; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Ticlopidine; Treatment Outcome; Warfarin

Non-vitamin K antagonist oral anticoagulants are used to prevent thromboembolism in patients with atrial fibrillation. The T-TAS "Total Thrombus-formation Analysis System" (Fujimori Kogyo Co Ltd) was developed for quantitative analysis of thrombus formation using microchips with thrombogenic surfaces (collagen, platelet chip [PL] ; collagen plus tissue factor, atheroma chip [AR]). We evaluated the utility of T-TAS in predicting periprocedural bleeding in atrial fibrillation patients undergoing catheter ablation (CA).. After exclusion of 20 from 148 consecutive patients undergoing CA, the remaining 128 patients were divided into 2 treatment groups: the warfarin group (n=30) and the non-vitamin K antagonist oral anticoagulants group (n=98). Blood samples obtained on the day of CA (anticoagulant-free point) and at 3 and 30 days after CA were used in T-TAS to compute the thrombus formation area under the curve (AUC; AUC for the first 10 minutes for PL tested at flow rate of 24 μL/min [PL24-AUC10]; AUC for the first 30 minutes for AR tested at flow rate of 10 μL/min [AR10-AUC30]). AR10-AUC30 and PL24-AUC10 levels were similar in the 2 groups on the day of CA. Levels of AR10-AUC30, but not PL24-AUC10, were significantly lower in the 2 groups at days 3 and 30 after CA. Multiple logistic regression analyses identified the AR10-AUC30 level on the day of CA as a significant predictor of periprocedural bleeding events (odds ratio 5.7; 95% CI 1.54-21.1; P=0.009). Receiver operating characteristic analysis showed that the AR10-AUC30 level on the day of CA significantly predicted periprocedural bleeding events (AUC 0.859, 95% CI 0.766-0.951; P<0.001). The cutoff AR10-AUC30 level was 1648 for identification of periprocedural bleeding events.. These results suggested that the AR10-AUC30 level determined by T-TAS is a potentially useful marker for prediction of bleeding events in atrial fibrillation patients undergoing CA.

Topics: Administration, Oral; Aged; Anticoagulants; Area Under Curve; Atrial Fibrillation; Blood Coagulation; Blood Coagulation Tests; Blood Loss, Surgical; Catheter Ablation; Drug Monitoring; Equipment Design; Female; Humans; Lab-On-A-Chip Devices; Male; Microchip Analytical Procedures; Middle Aged; Postoperative Hemorrhage; Predictive Value of Tests; Retrospective Studies; Risk Assessment; Risk Factors; ROC Curve; Time Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Blood Coagulation Factors; Blood Loss, Surgical; Coagulants; Elective Surgical Procedures; Emergency Medical Services; Humans; International Normalized Ratio; Preoperative Care; Risk Factors; Thrombosis; Warfarin

Topics: Administration, Oral; Anticoagulants; Antithrombins; Blood Loss, Surgical; Cataract Extraction; Dabigatran; Eye Hemorrhage; Factor Xa Inhibitors; Humans; Pyrazoles; Pyridones; Rivaroxaban; Warfarin

The perioperative use of antithrombotic therapy is associated with increased bleeding risk after cardiac implantable electronic device (CIED) implantation. Topical application of tranexamic acid (TXA) is effective in reducing bleeding complications after various surgical operations. However, there is no information regarding local TXA application during CIED procedures. The purpose of our study was to evaluate bleeding complications rates during CIED implantation with and without topical TXA use in patients receiving antithrombotic treatment.. We conducted a retrospective analysis of consecutive patients undergoing CIED implantation while receiving warfarin or dual antiplatelet (DAPT) or warfarin plus DAPT treatment. Study population was classified in two groups according to presence or absence of topical TXA use during CIED implantation. Pocket hematoma (PH), major bleeding complications (MBC) and thromboembolic events occuring within 90 days were compared.. A total of 135 consecutive patients were identified and included in the analysis. The mean age was 60 ± 11 years old. Topical TXA application during implantation was reported in 52 patients (TXA group). The remaining 83 patients were assigned to the control group. PH occurred in 7.7 % patients in the TXA group and 26.5 % patients in the control group (P = 0.013). The MBC was reported in 5.8 % patients in the TXA and 20.5 % patients in control group (P = 0.024). Univariate logistic regression analysis identified age, history of recent stent implantation, periprocedural spironolactone use, periprocedural warfarin use, perioperative warfarin plus DAPT use, cardiac resynchronization therapy, and topical TXA application during CIED implantation as predicting factors of PH. Multivariate analysis showed that perioperative warfarin plus DAPT use (OR = 10.874, 95 % CI: 2.496-47.365, P = 0.001) and topical TXA application during CIED procedure (OR = 0.059, 95 % CI: 0.012-0.300, P = 0.001) were independent predictors of PH. Perioperative warfarin plus DAPT use and topical TXA application were also found to be independent predictors of MBC in multivariate analyses. No thromboembolic complications was recorded in the study group.. The present study demonstrated that the topical TXA application during CIED implantation is associated with reduced PH and MBC in patients with high bleeding risk.

Topics: Administration, Topical; Aged; Antifibrinolytic Agents; Blood Loss, Surgical; Chi-Square Distribution; Drug Administration Schedule; Drug Therapy, Combination; Female; Fibrinolytic Agents; Hematoma; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Platelet Aggregation Inhibitors; Prosthesis Implantation; Retrospective Studies; Risk Factors; Time Factors; Tranexamic Acid; Treatment Outcome; Warfarin

Anticoagulation with warfarin following bioprosthetic mitral valve replacement (BMVR) is recommended by multiple practice guidelines. We assessed practice variability and patient characteristics associated with warfarin prescription following BMVR.. We analyzed 7,637 patients in the Society of Thoracic Surgeons Database (January 1, 2008 to June 30, 2011) who were discharged following isolated primary nonemergent BMVR. Patients requiring preoperative warfarin, those with preoperative atrial fibrillation, or those with a contraindication to warfarin were excluded. The association between patient, hospital, and surgeon characteristics and warfarin prescription were evaluated.. Fifty-eight percent of this cohort (median age, 66 years; female sex, 58.7%) was prescribed warfarin. Patients receiving warfarin were older (67 vs 65 years; P < .0001), were less likely to have had preoperative stroke (9.3% vs 12.1%; P < .001), CHF (51.4% vs 54.1%; P < .02), or dialysis (4.9% vs 9.0%; P < 0.001), and had a longer postoperative length of stay (8.0 vs 7.0 days; P < 0.01). Warfarin was prescribed less often for patients with postoperative GI events (44.4% vs 55.6%; P < .001) but more often for patients with postoperative myocardial infarction (75.8% vs 24.2%; P < .001) or new atrial fibrillation (68% vs 32%; P < .001) and those requiring blood transfusions intraoperatively (55.7% vs 44.3%; P < .001) or postoperatively (57% vs 43%; P < .03). Similar rates of warfarin prescription were observed in patients requiring reoperation for bleeding (54.9% vs 45.1%; P = .20) and those with postoperative stroke (53.6 % vs 46.4 %; P = .30). After adjusting for patient characteristics, significant surgeon and hospital variation in warfarin prescription at hospitals was observed.. Although patient characteristics and postoperative events may be associated with the prescription of warfarin following BMVR, substantial surgeon and hospital variability remains. This variability largely ignores the established practice guidelines and warrants further study to define the optimal anticoagulation strategy in patients undergoing BMVR.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Blood Loss, Surgical; Blood Transfusion; Databases, Factual; Female; Guideline Adherence; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Multivariate Analysis; Myocardial Infarction; Patient Discharge; Postoperative Complications; Postoperative Hemorrhage; Practice Guidelines as Topic; Practice Patterns, Physicians'; Renal Dialysis; Stroke; Warfarin

Patients with congenital Factor XIII (FXIII) deficiency have impaired fibrin stabilization and are at high risk for surgical bleeding. Data regarding the use of FXIII concentrates before and during surgery are lacking. The objective of this study was to report the use of plasma-derived FXIII concentrate (Corifact in the United States; Fibrogammin P in other countries) in patients with congenital FXIII deficiency undergoing surgical procedures.. FXIII concentrate at preoperative doses ranging from 25 to 40 U/kg was administered to six patients with congenital FXIII deficiency undergoing major or minor surgeries.. FXIII concentrate was administered immediately before surgery for five surgical cases; three of these patients achieved excellent hemostasis during and after surgery, while two had intraoperative bleeding. In one surgical case, a regular prophylactic dose of FXIII concentrate was administered to the patient 1 week before minor surgery. FXIII concentrate provided rapid replacement of FXIII activity. In all but one of the patients given a dose of FXIII designed to increase FXIII levels more than 50%, there was satisfactory intraoperative and postoperative hemostasis. One patient undergoing aortic valve replacement on cardiopulmonary bypass (CPB) was the exception. Intraoperative bleeding in this patient was associated with lower-than-expected blood levels of FXIII.. Preoperative plasma-derived FXIII concentrate allowed for sufficient hemostasis in most patients with FXIII deficiencies. Additional doses were necessary to achieve hemostasis in one patient who underwent a CPB procedure.

Topics: Adolescent; Adult; Aged; Anticoagulants; Blood Loss, Surgical; Factor XIII; Factor XIII Deficiency; Female; Humans; Male; Middle Aged; Oral Hemorrhage; Postoperative Hemorrhage; Preoperative Care; Thrombosis; Warfarin

In patients with atrial fibrillation (AF) who require interruption of dabigatran or warfarin for an elective surgery/procedure, the risks and benefits of perioperative bridging anticoagulation is uncertain.We accessed the database from RE-LY, a randomised trial comparing dabigatran with warfarin for stroke prevention in AF, to assess the potential benefits and risks of bridging. In patients who had a first interruption of dabigatran or warfarin for an elective surgery/procedure, we compared the risk for major bleeding (MB), stroke or systemic embolism (SSE) and any thromboembolism (TE) in patients who were bridged or not bridged during the period of seven days before until 30 days after surgery/procedure. We used multivariable Cox regression to adjust for potential confounders.Bridging was used more during warfarin interruption than dabigatran interruption (27.5 % vs 15.4 %; p< 0.001). With dabigatran interruption, bridged patients had more MB (6.5 % vs 1.8 %, p< 0.001) than those not bridged but bridged and not bridged groups did not differ for any TE (1.2 % vs 0.6 %, p=0.16) and SSE (0.5 % vs 0.3 %, p=0.46). With warfarin interruption, bridged patients had more MB (6.8 % vs 1.6 %, p< 0.001) and any TE (1.8 % vs 0.3 %, p=0.007) than those not bridged but bridged and not bridged groups did not differ for SSE (0.5 % vs 0.2 %, p=0.321). In conclusion, in patients who interrupted dabigatran or warfarin for a surgery/ procedure in the RE-LY trial, use of bridging anticoagulation appeared to increase the risk for major bleeding irrespective of dabigatran or warfarin interruption.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Dabigatran; Drug Administration Schedule; Elective Surgical Procedures; Female; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Perioperative Care; Postoperative Hemorrhage; Propensity Score; Proportional Hazards Models; Randomized Controlled Trials as Topic; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Surgical Procedures, Operative; Time Factors; Treatment Outcome; Warfarin

Patients treated with warfarin for therapeutic anticoagulation present a challenge for the perioperative management of urgent and emergent surgery. Anticoagulation must be reversed prior to most surgical procedures to prevent intraoperative bleeding. The purpose of this module is to review the options for urgent reversal of warfarin anticoagulation and the indications for each reversal agent. Selection of the appropriate agent is important to reduce unnecessary complications of treatment and to achieve optimal reversal of anticoagulation.. When urgent surgery is required for patients taking warfarin, intravenous vitamin K1 should be used for procedures that can be delayed for six to 12 hr. Vitamin K1 results in the activation of existing clotting factors rather than requiring the synthesis of new proteins, which allows for its relatively rapid onset of action. Intravenous vitamin K1 acts more quickly than oral administration, with reversal of anticoagulation occurring within six to 12 hr vs 18-24 hr, respectively. If surgery cannot be delayed, prothrombin complex concentrates (PCCs) should be given, and intravenous vitamin K1 should be infused concurrently to ensure sustained reversal of anticoagulation. The duration of action of both PCCs and plasma is six hours due to the short half-life of factor VII. Prothrombin complex concentrates contain small amounts of heparin and are contraindicated in patients with heparin-induced thrombocytopenia. Plasma should be used only if PCCs are unavailable or are contraindicated.. Reversal of warfarin anticoagulation can be achieved in a safe and timely manner when the appropriate agent is selected and administered correctly.

Topics: Anticoagulants; Blood Coagulation Factors; Blood Loss, Surgical; Hemorrhage; Humans; Preoperative Care; Time Factors; Vitamin K 1; Warfarin

Topics: Blood Loss, Surgical; Courage; Decision Making; Elective Surgical Procedures; Female; Humans; Male; Patient Safety; Patients; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Practice Patterns, Physicians'; Preoperative Care; Prognosis; Rhytidoplasty; Risk Assessment; Treatment Outcome; Warfarin

Many ophthalmologists consider switching patients on chronic warfarin anticoagulation to enoxaparin or discontinuing their anticoagulant for strabismus surgery. We report 3 successful cases of strabismus surgery on patients taking warfarin. No excessive bleeding was encountered intraoperatively or during the recovery period. To our knowledge, this is the first report regarding the safety of strabismus surgery in patients who are maintained on warfarin during strabismus surgery.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Female; Humans; Male; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Postoperative Hemorrhage; Retrospective Studies; Strabismus; Warfarin

Significant blood loss in neck-of-femur (NOF) fracture surgery contributes to the high morbidity and mortality. Since the introduction of the European Working Time Directive, trainee surgeons are more junior and inexperienced. We assessed NOF surgical blood loss in relation to the surgeon grade and experience. We assessed a prospective consecutive cohort of 105 acute NOF fracture patients treated surgically. Blood loss was calculated as the difference between the pre- and post-operative haemoglobin levels. Warfarin was reversed pre-operatively where necessary. There were 32 male and 73 female patients, with mean age 83.8 years (range 48-98). One patient died peri-operatively and was excluded. There were 49 intra-capsular fractures and 55 extra-capsular fractures, with no significant difference in group characteristics. Mean haemoglobin drop was 2.8 g/dL [intra-capsular fractures, 2.5 g/dL; extra-capsular fractures, 3.1 g/dL (p = 0.019)]. The difference in blood loss between different surgeon grades was not significant: consultants 2.4 g/dL (21 cases), senior staff grades 2.7 g/dL (17 cases), junior staff grades 3.1 g/dL (15 cases) and registrars 2.9 g/dL (50 cases). Whilst mean haemoglobin drop was least for consultants, the mean for trainees was only marginally higher than for experienced staff grade surgeons and lower than for their junior counterparts. Mean blood loss for patients taking anti-platelet agents was not significantly different (aspirin 2.7 g/dL, clopidogrel 3.7 g/dL, 4.4 g/dL for those taking both) compared to patients taking neither agent (2.8 g/dL). We conclude that surgeon grade does not significantly impact peri-operative haemoglobin drop, regardless of pre-operative morbidity. It is safe for trainees to operate, with adequate supervision where appropriate, on all NOF fracture patients without compromising blood loss.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Clinical Competence; Drug Substitution; Education, Medical, Continuing; Female; Femoral Neck Fractures; Fracture Fixation; Hemoglobins; Humans; Male; Middle Aged; Monitoring, Physiologic; Orthopedics; Outcome and Process Assessment, Health Care; Prospective Studies; United Kingdom; Warfarin

To describe the pharmacologic agents and strategies used for urgent reversal of warfarin and the target-specific oral anticoagulants dabigatran, rivaroxaban, and apixaban.. To reverse the anticoagulant effects of warfarin in patients who are bleeding or need surgery, exogenous vitamin K (phytonadione) may be used in combination with another, shorter-acting intervention, such as fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), recombinant factor VIIa, or activated PCC (aPCC). Three-factor PCC contains factors II, IX, and X in an inactivated form, and four-factor PCC also includes factor VII in an inactivated form. No four-factor PCC products are available in the United States, but aPCC, which contains the same four factors with factor VII provided in an activated form, is available. The intervention depends on the International Normalized Ratio, presence of bleeding, and need for and timing of surgery. Research suggests that clotting factor concentrates are more effective than FFP alone for warfarin reversal. These products also may be useful for reversing the effects of target-specific oral anticoagulants, but limited efficacy and safety data are available to support their use. The risks and benefits associated with these products need to be weighed before their use for reversal of dabigatran, rivaroxaban, or apixaban. Additional clinical data are needed to clearly define the role of concentrated clotting factor products in reversal and to determine the optimal clotting factor concentrate product and dose for urgent reversal of oral anticoagulation.. Phytonadione and clotting factor concentrates appear to have a role for reversal of warfarin, and limited evidence suggests that clotting factor concentrates could have a role in reversal of target-specific oral anticoagulants in an emergency situation.

Topics: Administration, Oral; Anticoagulants; Antifibrinolytic Agents; Antithrombins; Benzimidazoles; beta-Alanine; Blood Coagulation Factors; Blood Loss, Surgical; Dabigatran; Drug Therapy, Combination; Emergencies; Hemorrhage; Humans; International Normalized Ratio; Morpholines; Plasma; Pyrazoles; Pyridones; Rivaroxaban; Surgical Procedures, Operative; Thiophenes; Thromboembolism; Treatment Outcome; Vitamin K 1; Warfarin

The American College of Chest Physicians provides recommendations for the use of anticoagulant medications for several indications that are important in the primary care setting. Warfarin, a vitamin K antagonist, is recommended for the treatment of venous thromboembolism and for the prevention of stroke in persons with atrial fibrillation, atrial flutter, or valvular heart disease. When warfarin therapy is initiated for venous thromboembolism, it should be given the first day, along with a heparin product or fondaparinux. The heparin product or fondaparinux should be continued for at least five days and until the patient's international normalized ratio is at least 2.0 for two consecutive days. The international normalized ratio goal and duration of treatment with warfarin vary depending on indication and risk. Warfarin therapy should be stopped five days before major surgery and restarted 12 to 24 hours postoperatively. Bridging with low-molecular-weight heparin or other agents is based on balancing the risk of thromboembolism with the risk of bleeding. Increasingly, self-testing is an option for selected patients on warfarin therapy. The ninth edition of the American College of Chest Physicians guidelines, published in 2012, includes a discussion of anticoagulants that have gained approval from the U.S. Food and Drug Administration since publication of the eighth edition in 2008. Dabigatran and apixaban are indicated for the prevention of systemic embolism and stroke in persons with nonvalvular atrial fibrillation. Rivaroxaban is indicated for the prevention of deep venous thrombosis in patients undergoing knee or hip replacement surgery, for treatment of deep venous thrombosis and pulmonary embolism, for reducing the risk of recurrent deep venous thrombosis and pulmonary embolism after initial treatment, and for prevention of systemic embolism in patients with nonvalvular atrial fibrillation.

Topics: Anticoagulants; Atrial Fibrillation; Blood Coagulation; Blood Coagulation Tests; Blood Loss, Surgical; Drug Interactions; Drug Monitoring; Heart Valve Diseases; Hemorrhage; Humans; International Normalized Ratio; Outpatients; Practice Guidelines as Topic; Stroke; Venous Thromboembolism; Warfarin

The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized.. To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion.. This was a retrospective cohort study in a high-volume tertiary care center.. Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery.. The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused.. The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed.. The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused.. Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Cohort Studies; Female; Humans; Lumbar Vertebrae; Male; Middle Aged; Orthopedic Procedures; Retrospective Studies; Warfarin

Bleeding-related wound complications cause significant morbidity in lower limb arthroplasty surgery. Patients who require therapeutic anticoagulation in the perioperative period are potentially at higher risk for these complications. This is a retrospective case-control study reviewing all primary total hip arthroplasties performed in a single center during a 5-year period and comparing outcomes of the patients on warfarin with a double-matched control group of patients not on warfarin. The warfarin group had a significantly higher risk of deep joint infection (9% vs 2.2%), hematoma/wound ooze (28% vs 4%), and superficial infection (13.5% vs 2.2%). Managing patients undergoing total hip arthroplasty with therapeutic anticoagulation is a balance between the risk of thromboembolic disease and bleeding-related complications. Improved understanding of this risk will better allow patients to make an informed decision regarding their elective arthroplasty surgery.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Case-Control Studies; Female; Heparin; Humans; Male; Middle Aged; Postoperative Hemorrhage; Prosthesis-Related Infections; Reoperation; Surgical Wound Infection; Thromboembolism; Warfarin

Risk for bleeding complications during and after early hip fracture surgery for patients taking clopidogrel and other anticoagulants have not been defined. The purpose of this study is to assess the perioperative bleeding risks and clinical outcome after early hip fracture surgery performed on patients taking clopidogrel (Plavix) and other oral anticoagulants.. Study design is a retrospective cohort analysis using data extracted from hospital records and state death records.. Regional medical center (level II trauma).. Data for 1118 patients ≥60 years of age who had surgical treatment for a hip fracture between 2004 and 2008 were reviewed. Eighty-two patients undergoing late surgery (>3 days after admission) were excluded. Patients taking clopidogrel were compared against those not taking clopidogrel. In addition, patients taking clopidogrel only were compared against cohorts of patients taking both clopidogrel and aspirin, aspirin only, warfarin only, or no anticoagulant.. Seventy-four of 1036 patients (7%) were taking clopidogrel, although control groups included 253 patients on aspirin alone, 90 patients on warfarin, and 619 taking no anticoagulants. No significant differences were noted between patients taking clopidogrel and those not taking clopidogrel in estimated blood loss, transfusion requirement, final blood count, hematoma evacuation, hospital length of stay (LOS), or mortality while in hospital or at 1 year. A higher American Society of Anesthesiologists score was seen in the clopidogrel and warfarin groups (P = 0.05 each), increased LOS in the clopidogrel group (P = 0.05), and higher rate of deep vein thrombosis seen in those patients taking warfarin (P = 0.05). Clopidogrel only versus aspirin versus both aspirin and clopidogrel, versus no anticoagulant versus warfarin showed no significant differences in estimated blood loss, transfusion requirement, final blood count, bleeding or perioperative complications, or mortality.. Patients undergoing early hip fracture surgery who are taking clopidogrel, aspirin, or warfarin (with regulated international normalized ratio) are not at substantially increased risk for bleeding, bleeding complications, or mortality. Comorbidities and American Society of Anesthesiologists scores were significantly higher in the clopidogrel group, which may have resulted in the increased postoperative LOS in this group.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Cohort Studies; Female; Hip Fractures; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Ticlopidine; Treatment Outcome; Warfarin

To assess the use of Prothrombinex-VF powder for injection (PTX-VF) at Royal Perth Hospital and analyse the efficacy and safety profile of PTX-VF.. A prospective observational audit of PTX-VF use, conducted by reviewing medical records and laboratory and imaging results for all patients prescribed PTX-VF from 1 November 2009 to 1 May 2010.. Data on indication, diagnosis, comorbidities, dose of PTX-VF, fresh frozen plasma (FFP) and vitamin K, coagulation parameters before and after PTX-VF administration, and adverse effects.. 334 vials of PTX-VF were administered to 84 patients over 107 prescriptions. Indications were warfarin reversal, intraoperative bleeding and coagulopathy (66, 20 and 21 prescriptions, respectively). PTX-VF with FFP was compared with PTX-VF alone for warfarin reversal and there was a significant decrease in international normalised ratio (INR) that was independent of group (P < 0.001). Lower doses of PTX-VF (< 25 IU/kg) were compared with higher doses (25-50 IU/kg) for warfarin reversal and decrease in INR was significant, independent of group (P = 0.002). PTX-VF was administered for intraoperative bleeding in 18 patients who had not been treated with warfarin. No hypersensitivity reactions, thrombotic complications or worsening of disseminated intravascular coagulation occurred during 7-day follow-up.. For warfarin reversal, lower doses of PTX-VF (< 25 IU/kg) and PTX-VF without FFP were effective. PTX-VF was also used in intraoperative bleeding and non-warfarin coagulopathy. No adverse events were associated with PTX-VF.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Factors; Blood Loss, Surgical; Female; Hemorrhage; Humans; Injections; International Normalized Ratio; Male; Middle Aged; Plasma; Warfarin; Young Adult

Currently, there is very limited literature on the effect of long-term anticoagulants on total knee arthroplasty. The primary purpose of this study was to determine the effect of warfarin and clopidogrel on the transfusion rate, intra-operative blood loss, and postoperative blood loss for total knee arthroplasty. The secondary purpose was to determine their effect on post operative wound complications and length of stay. Data was collected retrospectively from medical charts between 2003-2008 and case matched to a control group. The patients on warfarin had a higher rate of blood transfusion, blood loss, and length of hospital stay compared to the clopidogrel and control groups.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Clopidogrel; Elective Surgical Procedures; Female; Humans; Length of Stay; Male; Platelet Aggregation Inhibitors; Preoperative Care; Retrospective Studies; Ticlopidine; Warfarin

This study aimed to teach dental students to use an INRatio® (HemoSense) device, to apply the results to patients, and to evaluate the outcomes.. This was a retrospective convenience data study that used student surveys.. The research was conducted at The Ohio State University College of Dentistry Geriatric Dental Program in Columbus, Ohio.. A total of 105 senior dental students participated in an INRatio training program.. The instructions involved the following: 1) a table showing INRatio protocol and dental procedures versus international normalized ratio (INR) guidelines; 2) an online technique training course, 3) a trial INRatio test on another senior dental student; and 4) INRatio for a dental patient.. The clinical outcomes including INR values were a retrospective convenience data study. Instructional outcomes were obtained from student surveys.. A total of 79% of students indicated they would use portable INR testing in their future practices; however, 73% of students had difficulty obtaining an adequate blood sample. All patient surgical procedures were completed successfully without serious complications.. This study indicates the INRatio analysis can be included in dental student training, providing safe, efficient, and successful patient care. Difficulty obtaining blood samples suggests the need for extra training, additional clinical experience, and INR devices requiring smaller blood samples.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Blood Specimen Collection; Computer-Assisted Instruction; Dental Care; Education, Dental; Female; Follow-Up Studies; Humans; International Normalized Ratio; Male; Minor Surgical Procedures; Online Systems; Oral Surgical Procedures; Point-of-Care Systems; Postoperative Hemorrhage; Practice Guidelines as Topic; Retrospective Studies; Students, Dental; Teaching; Teaching Materials; Warfarin

Periprocedural interruptions in warfarin therapy increase thromboembolic risks to patients and are not indicated for all procedures. We sought to determine the frequency and guideline concordance of periprocedural warfarin interruptions to inform a future educational intervention.. In October and November of 2009, an anonymous postal survey was sent to all patients followed for more than 1 year by the University of Michigan Anticoagulation service. Patients were asked how many times in the prior year they were requested to interrupt warfarin therapy for a medical or dental procedure or test and the specific indication for the requested interruption in warfarin therapy. A total of 1686 of 2133 (79%) subjects responded. The mean age of respondents was 69 years (SD=14 years). The majority were men (56%) and white (93%). Atrial fibrillation was the most common indication for warfarin therapy (n=966, 57%). At least 1 request to interrupt warfarin therapy in the prior year was given by 819 of 1648 (50%) respondents, including 481 of the 947 (51%) respondents taking warfarin for atrial fibrillation. Forty-eight percent of requests to interrupt warfarin among all respondents and 50% of requests to interrupt warfarin among those taking warfarin, specifically for atrial fibrillation, were for indications not supported by guideline statements.. Periprocedural requests to interrupt warfarin therapy are common and are often discordant with current guidelines. Educational interventions may decrease risk of periprocedural thromboembolic complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Contraindications; Data Collection; Female; Humans; Male; Middle Aged; Oral Surgical Procedures; Patient Compliance; Preoperative Care; Risk Factors; Stroke; Surgical Procedures, Operative; Thromboembolism; Warfarin

Warfarin is increasingly used to prevent thromboembolism but adverse drug events (ADEs) are common. The National Safety Goals (3E) 2008 recommend that institutions develop processes to monitor the safe use of warfarin. Despite these guidelines, adverse events (bleeding) are common. This initiative, in an academic hospital, tracked warfarin use before and after using a PI process aimed at improving safe use of warfarin in hospitalized adults.. Retrospective (PRE-initiative, September-December 2007) and prospective (POST-initiative, January-December 2008) data were collected on in-hospital and prior warfarin use, demographics, medical history, initial and in-hospital warfarin maintenance dosing, hematocrit, International Normalized Ratio (INR), hepatic and renal function and adverse events related to warfarin use. Education on the appropriate use of warfarin was provided through formal and informal sessions and during daily hand-off sessions.. A total of 308 patients receiving oral warfarin were examined (mean age 70 ± 17(SD) years, 47% males, 36% from nursing homes). Age, sex ratios, and place of residence were similar PRE- versus POST-initiative. Overall initial and maintenance warfarin doses were significantly lower POST-initiative (P = .0129 and P = .0319, respectively) and these decreases occurred exclusively in patients with supratherapeutic INR levels (>3.0). During the POST-period, the prevalence of high INR levels and bleeding events during hospitalization also decreased significantly (P = .015 and P < .0005, respectively). Finally, concomitant use of anticoagulant and/or antiplatelet drugs was significantly decreased POST-initiative (P = .028).. Most hospitalized patients (PRE- and POST-) presented with INRs in the sub- or supratherapeutic ranges (<2 and >3, respectively), requiring warfarin dose adjustments. Education through this initiative resulted in significantly lower average maintenance doses of warfarin, less use of concomitant anticoagulant or antiplatelet drugs, fewer supratherapeutic range INRs, and fewer adverse events during warfarin therapy. Education through a PI initiative is a simple and effective means to implement safer use of warfarin in the in-hospital setting.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Female; Humans; International Normalized Ratio; Male; Middle Aged; Nursing Homes; Outcome Assessment, Health Care; Preoperative Care; Quality Assurance, Health Care; Retrospective Studies; Risk Factors; Safety Management; Severity of Illness Index; Thromboembolism; Warfarin

The objective of this study was to compare blood loss resulting from surgical termination of pregnancy up to 12 weeks of gestation between women receiving anticoagulation therapy and healthy controls.. Women using heparin, low-molecular-weight heparin or warfarin requesting surgical abortion were enrolled and prospectively matched with nonanticoagulated controls. The primary outcome was procedural blood loss. Additional outcomes included postprocedure blood loss (prior to discharge and 7 days following the procedure using standardized feminine hygiene products) and hemoglobin change (preoperative vs. Postoperative Day 1).. Four anticoagulated subjects and six control subjects were included in the analysis. The median blood loss at the time of the procedure was 70 mL (range 6-187) for the anticoagulated group and 22.5 mL (range 10-100) for the control group (p=.33). The median blood loss in the postoperative period prior to discharge was 10.5 mL (range 1-11) for the anticoagulated group and 5.5 mL (range 2-35.4) for the control group (p=.82). There were no differences in use of hygiene products or mean hemoglobin change between groups. No interventions for bleeding were necessary at the time of the procedure.. Anticoagulated women appear to have an increase in blood loss during and immediately following first trimester surgical abortion as compared to healthy controls. However, this increase does not appear to be clinically significant.

Topics: Abortion, Induced; Adolescent; Adult; Anticoagulants; Blood Loss, Surgical; Female; Hemoglobins; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Postoperative Hemorrhage; Pregnancy; Pregnancy Trimester, First; Prospective Studies; Treatment Outcome; Warfarin; Young Adult

Topics: Anticoagulants; Antifibrinolytic Agents; Antithrombins; Aspirin; Blood Loss, Surgical; Blood Transfusion; Clopidogrel; Coagulants; Factor Xa Inhibitors; Fibrinolytic Agents; Hemostasis, Surgical; Heparin; Humans; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Risk Assessment; Ticlopidine; Vitamin K; Warfarin

Therapeutic (international normalized ratio, INR 2.0-3.5) oral anticoagulation (TOAC) is assumed to increase perioperative bleeding complications and a standard recommendation is to discontinue warfarin before coronary bypass grafting (CABG).. To assess the safety of TOAC we retrospectively analyzed consecutive patients (n=270) with long-term warfarin therapy referred for CABG in two centers where TOAC strategy is employed. The main in-hospital outcomes of interest were death, stroke, acute myocardial infarction, new onset renal failure, resternotomy, and their composite. In the TOAC group of 103 patients CABG was performed during therapeutic oral anticoagulation and in the control group (81 patients) preoperative INR was lowered to a subtherapeutic (≤1.5) level.. The patients in TOAC group were more often operated on an emergency basis (p=0.02) and their EuroSCORE was higher (p=0.02). There were no significant differences in the major outcome events or their composite (17.5 vs. 11.1%, p=0.30) between the groups. Patients in the TOAC group had more postoperative blood loss (941±615 vs. 754±610 ml, p<0.01) and received more fresh frozen plasma (2.8±3.0 vs. 1.3±2.4 units, p<0.001), but transfused red blood cells (2.1±2.8 vs. 2.1±3.4 units) were comparable in the groups. Preoperative clopidogrel (OR 4.8, 95% CI 1.4-16.2, p=0.01) and enoxaparin therapy (OR 2.6, 95% CI 1.1-6.5, p=0.04) were the only significant independent predictors for any major adverse event.. Our study suggests that CABG is a safe procedure during TOAC with no excess bleeding or major complications. Prospective trials are needed to confirm this observation.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Case-Control Studies; Coronary Artery Bypass; Drug-Related Side Effects and Adverse Reactions; Enoxaparin; Female; Humans; International Normalized Ratio; Intraoperative Complications; Male; Middle Aged; Retrospective Studies; Warfarin

To assess the safety of phacoemulsification cataract extraction in patients on combined anticoagulant and antiplatelet treatment.. Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.. Prospective interventional case series.. Consecutive patients with simple cataract on combined anticoagulant (warfarin) and antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment because of a high risk for thromboembolic events were included. Patients had cataract extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification, and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international normalized ratio and platelet functions were evaluated immediately before surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and postoperative ocular bleeding and other related complications were assessed.. Forty patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had phacoemulsification. Hemorrhagic complications were not observed at surgery or during the 1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1 implantation of a capsular tension ring due to partial zonulysis. No patient had a thromboembolic event.. In patients with uncomplicated cataract at high risk for thromboembolic events, phacoemulsification cataract surgery using a CCI under topical needle-free anesthesia was safely performed without discontinuing systemic anticoagulant and antiplatelet treatment.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Drug Therapy, Combination; Eye Hemorrhage; Female; Humans; Intraoperative Complications; Lens Implantation, Intraocular; Male; Middle Aged; Phacoemulsification; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Prothrombin Time; Risk Assessment; Thromboembolism; Ticlopidine; Warfarin

Patients on chronic oral anticoagulation can be challenging to manage in the perioperative period.. Review of patients on warfarin undergoing elective abdominal colon and rectal operations at a single institution from 2000 to 2006.. One forty-six patients underwent 165 abdominal procedures. Mean (±SEM) age was 67 ± 1 years; 59% of patients were men. Median estimated blood loss was 200 ml, and 19% received intraoperative blood products while 19% of patients received a postoperative transfusion. Sixteen patients (10%) experienced bleeding complications (three requiring reoperation). No risk factors for bleeding were identified by multivariate analysis (MVA). Five patients (3%) suffered a postoperative thromboembolic event. Preoperative anticoagulation for cerebrovascular disease was a risk factor for thromboembolism (p = 0.03). Overall operative morbidity was 30% with no identifiable risk factor in MVA. Mortality was nil.. Postoperative bleeding and thromboembolism in patients on chronic anticoagulation are not insignificant (10% and 3%, respectively). Patients on warfarin for cerebrovascular disease are at increased risk for thromboembolic events postoperatively and should be placed on appropriate prophylaxis and monitored.

Topics: Administration, Oral; Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Colonic Diseases; Female; Heparin, Low-Molecular-Weight; Humans; Male; Multivariate Analysis; Postoperative Complications; Postoperative Hemorrhage; Rectal Diseases; Thromboembolism; Warfarin

The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.

Topics: Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Evidence-Based Medicine; Humans; Perioperative Care; Platelet Aggregation Inhibitors; Risk Assessment; Surgical Procedures, Operative; Thromboembolism; Thrombolytic Therapy; Ticlopidine; Warfarin

What's known on the subject? and What does the study add? There is controversy over the use of anti-platelet and anti-coagulant drugs in men undergoing TURP with contradictory evidence on the effect of the drugs on bleeding following the operation, particularly for aspirin. If anti-platelet or anti-coagulant drugs are not stopped for TURP, there is an unacceptable burden of bleeding. If the drugs are stopped there is an unacceptable rate of cardiovascular events.. • To determine the morbidity associated with perioperative management of antiplatelet (AP) or anticoagulant (AC) medication and transurethral prostatectomy.. • A retrospective review was performed on 163 consecutive patients undergoing transurethural prostatectomy. • Patients were grouped according to the perioperative management of AP and AC medications: control patients not prescribed any AP/AC drugs (group 1), those on AP/AC who had ceased them perioperatively (group 2) and those whose AP/AC were continued (group 3). • Warfarin was withheld perioperatively for all patients. • Morbidity associated with increased blood loss and cardiovascular or cerebrovascular events was recorded and differences were analysed with SPSS version 16 software.. • There was a statistically significant increase in bleeding-associated morbidity in group 2 (13/65) and group 3 (6/7) compared with the controls (9/91) (P < 0.01). • Cardiovascular and cerebrovascular events were only seen in group 2 (6/65), statistically significantly higher than the event rate in the other groups (P ≤ 0.01). • All cardiovascular or cerebrovascular events occurred in patients prescribed these medications for secondary prevention.. • Patients taking AP or AC medications have a higher rate of perioperative bleeding compared with those who are not taking any. • However, for patients prescribed AP or AC medication for secondary prevention, withholding these medications results in an increased rate of cardiovascular and cerebrovascular complications. • Careful consideration of the risks and other management options should be undertaken before performing transurethural prostatectomy in this high risk group of patients.

Topics: Aged; Anticoagulants; Aspirin; Blood Loss, Surgical; Cardiovascular Diseases; Case-Control Studies; Cerebrovascular Disorders; Humans; Male; Perioperative Care; Platelet Aggregation Inhibitors; Prostatic Hyperplasia; Prostatic Neoplasms; Retrospective Studies; Transurethral Resection of Prostate; Warfarin

Topics: Anticoagulants; Aspirin; Blood Loss, Surgical; Humans; Male; Platelet Aggregation Inhibitors; Transurethral Resection of Prostate; Warfarin

Topics: Administration, Oral; Anticoagulants; Blood Loss, Surgical; Drug Administration Schedule; Elective Surgical Procedures; Evidence-Based Medicine; Heparin; Humans; Patient Selection; Postoperative Hemorrhage; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Surgical Procedures, Operative; Thromboembolism; Warfarin

We investigated the efficiency and convenience of a continuous warfarinization (CW) strategy during the periprocedural period of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) in comparison with the classic strategy of switching to heparin (SH).. We compared CW (n = 49) and SH (n = 55, 3 days before RFCA) in 104 patients who underwent RFCA of AF (77 males, 55 +/- 12 years old, paroxysmal AF: persistent AF = 63:41). During the procedure, the activated clotting time (ACT) was maintained between 350 and 400 seconds, and a requirement of H, postablation INR, and periprocedural complications were compared. Results were as follows: (1) in the CW group, the preprocedural INR (1.85 +/- 0.61 vs 1.05 +/- 0.12, P < 0.001) and the proportions of INR > 2.0 after RFCA (1st postprocedure day 61.2% vs 5.5%, P < 0.001; 2nd postprocedure day 83.3% vs 21.8%, P < 0.005) were higher, and the heparin requirement was lower (2012 +/- 998 U/30 minutes vs 2921 +/- 795 U/30 minutes, P < 0.001) than in the SH group. (2) The incidences of hemorrhagic complications (18.2% vs 18.4%, P = NS) or the major bleeding rates (reduced hemoglobin >or= 4 g/dL, requiring blood transfusion; 3.6% vs 12.2%, P = NS) were not significantly different in the CW group than in the SH group.. The periprocedural CW strategy maintains a more stable INR immediately after AF ablation without increasing hemorrhagic complications compared with the classic strategy of SH. Simple CW can replace SH in an experienced laboratory with a low risk of hemopericardium during AF ablation.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Catheter Ablation; Electrophysiology; Female; Follow-Up Studies; Heparin; Humans; International Normalized Ratio; Intraoperative Complications; Male; Middle Aged; Monitoring, Physiologic; Thromboembolism; Warfarin

To assess the risk for intraoperative and postoperative bleeding associated with antiplatelet and/or anticoagulant treatment in patients having uneventful phacoemulsification.. Kokura Memorial Hospital, Kitakyusyu, Japan.. In a nonrandomized case series, consecutive patients had phacoemulsification and intraocular lens implantation under sub-Tenon anesthesia. All patients were on warfarin, acetylsalicylic acid (aspirin) therapy, or both. Patients discontinued therapy 1 week before surgery (discontinuation group) or continued the therapeutic regimen until the time of surgery (maintenance group).. The discontinuation group comprised 182 patients and the maintenance group, 173 patients. There was no significant difference between the 2 groups in the mean prothrombin time-international normalized ratio in patients taking warfarin (P = .6). Although there was no significant intraoperative bleeding in any case, 47 eyes (16.5%) in the maintenance group and 31 eyes (10.8%) in the discontinuation group had a subconjunctival hemorrhage postoperatively (P = .0309). Minor postoperative ocular bleeding occurred in 11 eyes (4.0%) in the maintenance group and 7 eyes (2.5%) in the discontinuation group (P = .4). During the 1-month postoperative period, the mean change in corrected distance visual acuity was -0.462 logMAR +/- 0.331 (SD) in the maintenance group and -0.434 +/- 0.318 logMAR in the discontinuation group (P = .3).. Patients taking warfarin, aspirin, or both up to the time of phacoemulsification had a significantly higher incidence of subconjunctival hemorrhage than those who discontinued therapy. There was no significant difference between the 2 groups in the incidence of intraoperative and postoperative complications or in visual improvement.. The author has no financial or proprietary interest in any material or method mentioned.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Loss, Surgical; Eye Hemorrhage; Female; Humans; Incidence; Lens Implantation, Intraocular; Male; Middle Aged; Phacoemulsification; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Visual Acuity; Warfarin

In patients on high-level anticoagulant therapy (prothrombin time-international normalized ratio [PT-INR] ≥ 4.5), surgical procedures can be carried out with bridging therapy using heparin. However, surgical treatment options are severely limited in patients on high-level anticoagulant therapy and who have heparin-induced thrombocytopenia (HIT), as heparin use is contraindicated. We performed tooth extraction using prothrombin complex concentrate (PCC) in 2 HIT patients on high-level anticoagulation therapy (PT-INR ≥ 4.5). Five hundred units of PCC were administered intravenously, and after 15 minutes, it was confirmed that PT-INR was less than 2.0. Tooth extraction was then performed and sufficient local hemostasis was achieved. At 3 hours after tooth extraction, PT-INR was 2.0 or higher and later increased to 4.0 or higher, but postoperative bleeding was mostly absent. When performing tooth extraction in HIT patients on high-level anticoagulant therapy, favorable hemostatic management was achieved through sufficient local hemostasis and transient warfarin reversal using PCC.

Topics: Adult; Aspirin; Blood Coagulation Factors; Blood Loss, Surgical; Cellulose, Oxidized; Contraindications; Electrocoagulation; Female; Fibrinolytic Agents; Gingival Hemorrhage; Heart Failure; Heart-Assist Devices; Hematoma; Hemostatics; Heparin; Humans; International Normalized Ratio; Male; Molar, Third; Periapical Periodontitis; Pericoronitis; Plasma; Postoperative Hemorrhage; Prothrombin Time; Thrombosis; Tooth Extraction; Tooth, Impacted; Warfarin

The authors evaluated the prophylactic protocols with unfractionated heparin (UFH) and warfarin in Japanese patients who underwent total knee arthroplasty (TKA) for osteoarthritis knee in regard to bleeding complications. Fifty-six patients who underwent TKA for osteoarthritis knee with the use of methylmethacrylate were included. Subcutaneous UFH and warfarin were administered for thromboprophylaxis to the first group of 26 patients. The second group of 30 patients did not receive any pharmacological thromboprophylaxis and were used as controls. No significant differences were found between the 2 groups for operative and postoperative blood loss. There were no cases with major bleeding as a complication, but for 2 cases, the international normalized ratio high value exceeded the remedy limits, and temporary dosage discontinuance was required. There were no clinically important bleeding events in the 2 groups. No heparin-induced thrombocytopenia or warfarin-induced skin necrosis occurred. The authors conclude that the protocol with UFH and warfarin is safe for thromboprophylaxis against deep venous thrombosis and pulmonary embolism after TKA in Japanese patients, but its efficacy can only be resolved with further studies.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Female; Heparin; Humans; Male; Middle Aged; Osteoarthritis, Knee; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Venous Thrombosis; Warfarin

Topics: Adult; Aged; Anticoagulants; Blood Loss, Surgical; Catheterization, Central Venous; Colectomy; Female; Fibrinolytic Agents; Heparin; Humans; Male; Middle Aged; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Embolism; Thrombolytic Therapy; Tissue Plasminogen Activator; Venous Thrombosis; Warfarin

Guidelines concerning the prevention and treatment of pregnancy-associated venous thromboembolism (VTE) have been elaborated by the American College of Chest Physicians and published in Chest in 2008. In this review, they have been compared with European guidelines and discussed taking into account the papers published since 2008.Most recommendations are of low grade of evidence because randomized studies are lacking during pregnancy and many reflect guidelines proposed by experts. The decisions on the most appropriate prophylaxis, dose to be administered and moment of pregnancy for starting prophylaxis are often decided case by case after careful assessment of the risk of pregnancy-associated VTE, on one hand, and the risk for the mother, on the other.Risk factors (age >or= 35, obesity, history of VTE with or without sequellae, in vitro fertilization)or thrombophilia have to be taken into account. Scores have been proposed to improve standardisation and evaluation of the risk of VTE and they should be validated.

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Benzimidazoles; Blood Loss, Surgical; Cesarean Section; Contraindications; Dabigatran; Europe; Evidence-Based Medicine; Female; Fetus; Fondaparinux; Heparin; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Morpholines; Polysaccharides; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications, Hematologic; Puerperal Disorders; Pyridines; Rivaroxaban; Societies, Medical; Thiophenes; Thrombophilia; United States; Uterine Hemorrhage; Venous Thromboembolism; Warfarin

This study aims to establish the prevalence of aspirin, dipyridamole, clopidogrel, and warfarin use in patients undergoing cataract surgery, and to compare local anaesthetic and intraoperative complication rates between users and non-users.. The Cataract National Dataset was remotely extracted and anonymised on 55,567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006.. This report analyses 48,862 of the 55,567 operations from the eight centres, which routinely recorded a drug history. In all, 28.1% of the 48,862 patients were taking aspirin, 5.1% warfarin, 1.9% clopidogrel, and 1.0% dipyridamole. The recording of any complication of a sharp needle or subtenon's cannula local anaesthetic block was increased in patients taking clopidogrel, 8.0% (P<0.0001) or warfarin, 6.2% (P=0.0026) vs non-users, 4.3%, but no increase in potentially sight-threatening complications was identified. The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel, 4.4% (P<0.0001) or warfarin, 3.7% (P<0.0001) vs non-users, 1.7%. The recording of any operative complication was increased in those taking clopidogrel, 7.3% (P=0.0002) vs non-users, 4.4%, but the haemorrhagic operative complications of choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased. The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel, 3.23% (P=0.0057) vs non-users, 1.77%.. Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenon's cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications.

Topics: Aged; Anesthetics, Local; Anticoagulants; Aspirin; Blood Loss, Surgical; Cataract Extraction; Choroid Hemorrhage; Clopidogrel; Dipyridamole; Eye Hemorrhage; Humans; Intraoperative Complications; Lens Capsule, Crystalline; Platelet Aggregation Inhibitors; Risk Factors; Rupture; Ticlopidine; Warfarin

Significant uncertainty surrounds the treatment of patients who must discontinue warfarin sodium therapy before an invasive procedure. In part, the uncertainty results from the lack of published information about the risk of thromboembolism associated with short-term warfarin therapy interruption. We aimed to assess the frequency of thromboembolism and bleeding within a large cohort of patients whose warfarin therapy was temporarily withheld for an outpatient invasive procedure.. This prospective, observational cohort study was performed at 101 sites (primarily community-based physician office practices) in the United States. Enrollment was conducted from April 4, 2000, to March 6, 2002. The main outcome measures were thromboembolism or clinically significant hemorrhage within 30 days of warfarin therapy interruption.. A total of 1293 episodes of warfarin therapy interruption in 1024 individuals were included. The mean (SD) patient age was 71.9 (10.6) years; 438 (42.8%) were female. The most common indications for anticoagulant therapy were atrial fibrillation (n=550), venous thromboembolism (n=144), and mechanical heart valve (n=132). The most common procedures were colonoscopy and oral and ophthalmic surgery. Perioperative heparin or low-molecular-weight heparin was used in only 8.3% of cases overall. Seven patients (0.7%; 95% confidence interval [CI], 0.3%-1.4%) experienced postprocedure thromboembolism within 30 days. None of the 7 patients who experienced thromboembolism received periprocedural bridging therapy. Six patients (0.6%; 95% CI, 0.2%-1.3%) experienced major bleeding, whereas an additional 17 patients (1.7%; 95% CI, 1.0%-2.6%) experienced a clinically significant, nonmajor bleeding episode. Of these 23 patients who had bleeding episodes, 14 received periprocedural heparin or low-molecular-weight heparin. The duration of warfarin therapy interruption was variable; however, more than 80% of patients had warfarin therapy withheld for 5 days or fewer.. For many patients receiving long-term anticoagulation who need to undergo a minor outpatient intervention, a brief (< or =5 days) periprocedural interruption of warfarin therapy is associated with a low risk of thromboembolism. The risk of clinically significant bleeding, even among outpatients undergoing minor procedures, should be weighed against the thromboembolic risk of an individual patient before the administration of bridging anticoagulant therapy.

Topics: Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Anticoagulants; Blood Loss, Surgical; Cohort Studies; Female; Hemorrhage; Humans; Male; Middle Aged; Postoperative Hemorrhage; Preoperative Care; Prospective Studies; Risk Factors; Thromboembolism; Treatment Outcome; Warfarin; Withholding Treatment

To identify the practices of ophthalmologists when undertaking glaucoma surgery on patients concurrently using warfarin or acetylsalicylic acid (aspirin).. A questionnaire was designed to examine perioperative management of patients being treated with warfarin and aspirin prior to and during glaucoma surgery. The questionnaire was posted with stamped self-addressed envelopes to all glaucoma specialists registered on a glaucoma shared care scheme database.. Of the 93 eligible participants, 64 returned a completed questionnaire, representing a response rate of 68.8%. Twenty-one surgeons (32.8%) routinely stopped warfarin before surgery. Mean time prior to surgery of drug cessation was 4 days (range 2-7). Three surgeons (14.3%) routinely commenced heparin if they stopped warfarin. Ten (47.6%) never used heparin, while the remaining eight (38.1%) would use heparin depending upon the indication for anticoagulation. Forty-two surgeons (81.25%)were happy to operate only at an INR < or =3 at the time of surgery. The remainder (18.75%) were happy to operate at higher INRs, including two surgeons (3.1%) who would operate at any level. Twenty surgeons (31.2%) routinely stopped aspirin before surgery, while the rest did not. Of those who stopped aspirin, the mean time prior to surgery was 7.1 days (range 4-14 days).. The majority of surgeons do not stop warfarin or aspirin prior to glaucoma surgery. There is a great diversity in current practice with regard to the management of anticoagulant therapy prior to glaucoma surgery amongst glaucoma surgeons in England. Currently there is little information available to offer definitive guidance.

Topics: Anticoagulants; Aspirin; Blood Loss, Surgical; Glaucoma; Humans; International Normalized Ratio; Ophthalmology; Practice Patterns, Physicians'; Surveys and Questionnaires; Time Factors; Trabeculectomy; Warfarin

The management of patients on antiplatelet and anticoagulation therapy (APACT) in glaucoma surgery currently has no specific recommendations. We aimed to establish the risk of haemorrhagic complications and surgical outcome in patients on APACT in glaucoma surgery.. We retrospectively examined 367 consecutive trabeculectomies performed between 1994 and 1998. Preoperatively 60 (16.4%) patients were on APACT (55 on aspirin and five on warfarin). The incidence of hyphaema and haemorrhagic complications between patients with and without APACT was documented. Surgical success was defined in two categories as an intraocular pressure (IOP) <21 mmHg and an IOP <16 mmHg 2 years following trabeculectomy with and without antiglaucoma medication.. None of the patients on aspirin suffered significant intra or postoperative haemorrhage. Aspirin was associated with a significantly higher risk of hyphaema (P=0.0015) but this was not found to significantly affect IOP control at 2 years. Patients on warfarin suffered haemorrhagic complications and trabeculectomy failure.. Aspirin appears to be safe to continue with during trabeculectomy. Patients on aspirin have an increased risk of hyphaema following trabeculectomy. This however does not appear to affect surgical outcome. Warfarinised patients are at risk of serious bleeding complications. They require careful monitoring pre- and postoperatively and are at risk of trabeculectomy failure.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Aspirin; Blood Loss, Surgical; Child; Drug Administration Schedule; Epidemiologic Methods; Eye Hemorrhage; Glaucoma; Humans; Hyphema; Intraocular Pressure; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Trabeculectomy; Treatment Outcome; Warfarin

To evaluate the safety of inferior vena cava (IVC) filter retrieval in therapeutically anticoagulated patients in comparison to prophylactically or not therapeutically anticoagulated patients with respect to retrieval-related hemorrhagic complications.. This was a retrospective study of 115 consecutive attempted IVC filter retrievals in 110 patients. Filter retrievals were stratified as performed in patients who were therapeutically anticoagulated (group 1), prophylactically anticoagulated (group 2), or not therapeutically anticoagulated (group 3). The collected data included anticoagulant and antiplatelet medications (type, form and duration of administration, dosage) at the time of retrieval. Phone interviews and chart review was performed for the international normalized ratio (INR), activated partial thromboplastin time, platelet count, infusion of blood products, and retrieval-related hemorrhagic complications.. Group 1 included 65 attempted filter retrievals in 61 therapeutically anticoagulated patients by measured INR or dosing when receiving low-molecular-weight heparin (LMWH). Four retrievals were not successful. In patients receiving oral anticoagulation, the median INR was 2.35 (range, 2 to 8). Group 2 comprised 23 successful filter retrievals in 22 patients receiving a prophylactic dose of LMWH. Group 3 included 27 attempted filter retrievals in 27 patients not receiving therapeutic anticoagulation. Six retrievals were not successful. Five patients were receiving oral anticoagulation with a subtherapeutic INR (median, 1.49; range, 1.16 to 1.69). No anticoagulation medication was administered in 22 patients. In none of the groups were hemorrhagic complications related to the retrieval procedures identified.. These results suggest that retrieval of vena cava filters in anticoagulated patients is safe. Interruption or reversal of anticoagulation for the retrieval of vena cava filters is not indicated.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Cardiovascular Surgical Procedures; Child; Female; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Partial Thromboplastin Time; Platelet Count; Retrospective Studies; Risk Factors; Vena Cava Filters; Venous Thrombosis; Warfarin

Conflicting opinions exist in literature concerning the management of oral surgery in patients on oral anticoagulants because no consensus on perioperative protocols is available, including precise guidelines regarding the need for therapy modification or withdrawal. The aim of this study was to evaluate bleeding complications associated with oral surgery performed on patients on oral anticoagulants without therapy modification or withdrawal but following a standardized comprehensive perioperative management protocol.. Patients on oral anticoagulant therapy with warfarin and in need of oral surgery underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk; 255 subjects who, on the morning of surgery, had INR values

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Biopsy; Blood Loss, Surgical; Dental Implantation, Endosseous; Female; Humans; International Normalized Ratio; Male; Middle Aged; Oral Surgical Procedures; Patient Education as Topic; Perioperative Care; Postoperative Care; Postoperative Hemorrhage; Risk Assessment; Risk Factors; Safety; Thromboembolism; Tooth Extraction; Treatment Outcome; Warfarin

To assess the risks of intra- and postoperative bleeding tendency associated with uncomplicated cataract surgery by phacoemulsification in patients receiving Coumadin treatment.. Prospective, nonrandomized, interventional, consecutive case series.. Sixty-three consecutive patients underwent cataract extraction with lens implantation in 75 eyes. All patients were receiving Coumadin therapy at the time of surgery, and nine patients (14.3%) were also taking antiaggregants. The operations were performed by phacoemulsification technique under topical anesthesia. All patients underwent a hemostatic work-up before intervention. Structured questionnaires were completed by the surgeon immediately after the operation. In 18 (24%) eyes, the surgery was videotaped, and the tapes were reviewed subsequently for any bleedings by an independent observer.. Twelve patients (19%) underwent surgery in both eyes, not simultaneously. The mean prothrombin time international normalized ratio (INR) was 2.03 at the time of the surgery. No significant intraoperative bleeding occurred. Four (6.3%) patients had minor postoperative ocular bleeding. A microscopic hyphema and a dot retinal hemorrhage were each seen in one eye on the first postoperative day, and small iris hemorrhages were identified in two additional eyes at the one-week visit. All bleedings disappeared within one week without affecting the visual acuity. The mean INR of the four patients with minor bleedings was 2.1.. Cataract surgery by phacoemulsification in uncomplicated eyes can be performed safely in patients receiving Coumadin treatment. However, a large clinical trial is required to assess the safety of continuous Coumadin treatment associated with phacoemulsification in eyes with complicated cataract.

Topics: Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Eye Hemorrhage; Female; Humans; International Normalized Ratio; Lens Implantation, Intraocular; Male; Middle Aged; Phacoemulsification; Postoperative Hemorrhage; Prospective Studies; Prothrombin Time; Risk Assessment; Surveys and Questionnaires; Warfarin

Warfarin sodium is commonly prescribed for the prophylaxis and treatment of venous thromboembolism. Dosing algorithms have not been widely adopted because they require a fixed initial warfarin dose (eg, 5 mg) and are not tailored to other factors that may affect the international normalized ratio (INR).. To develop an algorithm that could predict a therapeutic warfarin dose based on drug interactions, INR response after the initial warfarin doses, and other clinical factors.. We used stepwise regression to quantify the relationship between these factors in patients beginning prophylactic warfarin therapy immediately prior to joint replacement. In the derivation cohort (n = 271), we separately modeled the therapeutic dose after 2 and 3 initial doses. We prospectively validated these 2 models in an independent cohort (n = 105).. About half of the therapeutic dose variability was predictable after 3 days of therapy: R2 was 53% in the derivation cohort and 42% in the validation cohort. INR response after 3 warfarin doses (INR3) inversely correlated with therapeutic dose (p < 0.001). Intraoperative blood loss transiently, but significantly, elevated the postoperative INR values. Other significant (p < 0.03) predictors were the first and second warfarin doses (+7% and +6%, respectively, per 1 mg), and statin use (-15.0%). The model derived after 2 warfarin doses explained 32% of the variability in therapeutic dose.. We developed and validated algorithms that estimate therapeutic warfarin doses based on clinical factors and INR response available after 2-3 days of warfarin therapy. The algorithms are implemented online at www.WarfarinDosing.org.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Algorithms; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Female; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; International Normalized Ratio; Male; Middle Aged; Prospective Studies; Pulmonary Embolism; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Blood Loss, Surgical; Humans; Platelet Aggregation Inhibitors; Postoperative Hemorrhage; Warfarin

Topics: Anticoagulants; Bleeding Time; Blood Coagulation Disorders; Blood Loss, Surgical; Dental Care for Chronically Ill; Gelatin Sponge, Absorbable; Hemostatic Techniques; Hemostatics; Humans; International Normalized Ratio; Oral Hemorrhage; Prothrombin Time; Tooth Extraction; Tranexamic Acid; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Blood Loss, Surgical; Contraindications; Drug Monitoring; Female; Humans; Middle Aged; Oral Hemorrhage; Stroke; Tooth Extraction; Warfarin

Patients requiring chronic anticoagulation are theoretically at increased risk for hemorrhage or thromboembolism perioperatively. Experience with laparoscopic renal/adrenal surgery in patients on chronic warfarin is limited. We assessed hemorrhagic/thromboembolic complications in this group of patients.. The records of 787 patients undergoing laparoscopic renal/adrenal surgery were retrospectively reviewed. A total of 25 patients on chronic oral anticoagulation with warfarin were identified. The indications for warfarin therapy as well as perioperative management were reviewed. Clinical parameters, including operative time, estimated blood loss, hemorrhagic/thromboembolic complications and transfusions, were documented and compared with those in patients not receiving chronic anticoagulation.. Atrial fibrillation (56% of cases) and a prosthetic mitral valve (28%) were the most frequent indications for chronic anticoagulation. Bridging anticoagulation with unfractionated heparin was the most frequent management method (68% of cases). Patients with anticoagulation were older (p <0.001) and hospitalized longer (<0.001) than those without anticoagulation. Operative time, estimated blood loss and the conversion rate were not significantly different between the groups. However patients on chronic warfarin significantly more often required transfusion (24% vs 5.2%, p <0.005) and had more postoperative bleeding episodes (8% vs 0.9%, p <0.05) than patients not on chronic anticoagulation. No thromboembolic events occurred in the anticoagulated group, while 3 occurred in the nonanticoagulated group (p = 1).. Laparoscopic renal/adrenal surgery in patients requiring chronic anticoagulation therapy can be performed safely. The risk of intraoperative bleeding is not increased, although the incidence of postoperative bleeding as well as transfusions is higher.

Topics: Administration, Oral; Adrenalectomy; Adult; Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Female; Humans; Laparoscopy; Long-Term Care; Male; Middle Aged; Nephrectomy; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk; Thromboembolism; Warfarin

The treatment of patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin sodium therapy is a common clinical problem. We investigated the efficacy and safety of a standardized periprocedural anticoagulation regimen with low-molecular-weight heparin.. We studied 650 consecutive patients with a mechanical heart valve, chronic atrial fibrillation, or embolic stroke who required interruption of warfarin therapy because of an invasive procedure. Warfarin was stopped 5 or 6 days before the procedure, and patients received subcutaneous dalteparin sodium, 100 IU/kg twice daily, starting 3 days before the procedure. The risk of postprocedural bleeding determined postprocedural anticoagulant management. In patients undergoing a non-high-bleeding-risk procedure who had adequate postprocedural hemostasis, warfarin was resumed on the evening of the procedure, and dalteparin sodium, 100 IU/kg twice daily, was resumed on the next day and continued until the international normalized ratio was 2.0 or more. If postprocedural hemostasis was not secured, the resumption of dalteparin was delayed. In patients undergoing a high-bleeding-risk procedure, warfarin was resumed on the evening of the procedure, but dalteparin was not given after the procedure.. Patients were followed up during the preprocedural and postprocedural period for a mean of 13.8 days (range, 10-18 days). In 542 patients who underwent a non-high-bleeding-risk procedure, there were 2 thromboembolic events (0.4%), 4 major bleeding episodes (0.7%), and 32 episodes of increased wound-related blood loss that precluded postprocedural dalteparin administration (5.9%). In 108 patients who underwent a high-bleeding-risk procedure, there were 2 deaths (1.8%) possibly due to thromboembolism and 2 major bleeding episodes (1.8%).. In patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin therapy, a standardized periprocedural anticoagulant regimen with low-molecular-weight heparin is associated with a low risk of thromboembolic and major bleeding complications.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Biomarkers; Blood Loss, Surgical; Female; Fibrinolytic Agents; Follow-Up Studies; Heart Valve Diseases; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Intracranial Embolism; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prospective Studies; Risk Factors; Surgical Procedures, Operative; Thromboembolism; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aspirin; Atrial Appendage; Atrial Fibrillation; Blood Loss, Surgical; Carotid Arteries; Dalteparin; Drug Administration Schedule; Elective Surgical Procedures; Filtration; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Care; Postoperative Care; Postoperative Complications; Postoperative Hemorrhage; Premedication; Stents; Thromboembolism; Thrombosis; Vitamin K; Warfarin

The purpose of this study was to validate a protocol for dental extraction in patients taking vitamin K antagonists without changing the treatment when the INR is lower than 2.8.. One hundred four extractions (96 patients) were performed during a 9 month period in patients taking vitamin K antagonists. Extraction was performed when the international normalized ratio (INR) was less than 2.8, otherwise, the treatment was modified until the desired INR was reached. Extractions were performed under para-apical and alveolar local anesthesia and sutured with hemostatic gauze.. Three patients developed postoperative bleeding requiring alveolar revision with local application of tranexamic acid and in one case use of a biological glue.. The following protocol can be proposed: ambulatory extraction under local anesthesia with an INR the day before extraction: the extraction is performed if the INR is<=2.8 using hemostatic gauze suture and tranexamic acid in case of persistent bleeding.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Blood Loss, Surgical; Child; Clinical Protocols; Dental Care for Chronically Ill; Female; Humans; International Normalized Ratio; Male; Middle Aged; Oral Hemorrhage; Phenindione; Retrospective Studies; Tooth Extraction; Tranexamic Acid; Vitamin K; Warfarin

The type of coagulation factors and proteins in cryoprecipitate determine the appropriate indications for its use. To determine the pattern of use at a tertiary care medical center, we performed a retrospective audit of cryoprecipitate utilization. A total of 51 patients received 88 pools of cryoprecipitate. In 39 patients, cryoprecipitate was transfused for appropriate indications: hypofibrinogenemia (n = 19), tissue plasminogen activator reversal (n = 1), management of massive transfusion (n = 7), correction of uremic bleeding (n = 2), and for making fibrin sealant (n = 10). Overall, these patients used approximately 80% of the cryoprecipitate transfused. In 12 other patients, cryoprecipitate was transfused inappropriately to attempt reversal of the anticoagulant effects of warfarin therapy (n = 6), to treat impaired surgical hemostasis in the absence of hypofibrinogenemia (n = 4), and to treat hepatic coagulopathy with multiple factor deficiencies (n = 2). The patterns of misuse, involving 24% of all cryoprecipitate orders, suggest a widespread misunderstanding and need for focused education about the coagulation factors and proteins present in cryoprecipitate and appropriate indications for its use.

Topics: Adult; Afibrinogenemia; Aged; Aged, 80 and over; Blood Loss, Surgical; Blood Transfusion; Factor VIII; Fibrin Tissue Adhesive; Fibrinogen; Hemorrhage; Humans; Liver Neoplasms; Medical Audit; Middle Aged; Retrospective Studies; Tissue Plasminogen Activator; Uremia; Warfarin

To determine whether there is a difference between on-pump cardiopulmonary bypass (CABG) and off-pump coronary artery bypass grafting (OPCAB) without heparin reversal with regard to bleeding, transfusion requirements, and incidence of surgical re-exploration of the mediastinum.. Retrospective chart review.. A large academic medical center.. Two hundred adult patients undergoing cardiac surgery.. None.. One hundred CABG patients were compared with 100 OPCAB patients. Statistical significance was measured with P values of

Topics: Aged; Aged, 80 and over; Anticoagulants; Biomarkers; Blood Loss, Surgical; Cardiopulmonary Bypass; Combined Modality Therapy; Coronary Artery Bypass; Coronary Disease; Creatinine; Erythrocyte Transfusion; Female; Humans; Incidence; Intensive Care Units; Intraoperative Care; Male; Mammary Arteries; Middle Aged; Multivariate Analysis; Platelet Transfusion; Postoperative Hemorrhage; Retrospective Studies; Serum Albumin; Sternum; Treatment Outcome; United States; Warfarin

Anticoagulant treatment with warfarin is an essential therapy in patients with prosthetic heart valves and atrial fibrillation to prevent thromboembolisms. The question whether to stop warfarin treatment in patients undergoing cutaneous surgery is debatable.. To evaluate the outcome of surgery in patients that were treated with warfarin and underwent excisional and Mohs surgeries.. Warfarin therapy was continued in all patients that underwent excisional and Mohs surgery in our practice from November 1999 to November 2000. Perioperative complications such as bleeding and cosmetic outcome are evaluated.. A total of 560 patients underwent Mohs surgery and 530 patients underwent excisional surgery. Sixteen patients (1.5%) were treated with coumadin with international normalized ratio (INR) values within the therapeutic values. Seventy-seven patients that underwent surgery on the same days as the warfarin-treated patients served as the control group. Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. All wounds healed without any complication, including full-thickness grafts.. Coumadin treatment should be continued in patients undergoing cutaneous surgery. This will decrease the risk of thromboembolic events.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Loss, Surgical; Contraindications; Dermatologic Surgical Procedures; Facial Neoplasms; Humans; Middle Aged; Mohs Surgery; Skin Neoplasms; Thromboembolism; Warfarin

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Cataract Extraction; Female; Humans; Hyphema; Lens Implantation, Intraocular; Male; Prospective Studies; Safety; Warfarin

Two patients undergoing cutaneous surgery had thromboembolic strokes within 1 week after surgery. Both patients had been taking warfarin for prevention of thromboembolism and warfarin was stopped 3-7 days prior to surgery.. To examine the rationale and problems associated with preoperative warfarin discontinuation.. Review of the medical literature.. When warfarin is stopped prior to surgery and restarted soon after surgery, the patient is at increased risk for thromboembolism. Although it is commonly believed that continuing warfarin during surgery is associated with an increased bleeding risk, for cutaneous surgery, this risk is extremely low and can be easily managed.. Warfarin should not be discontinued prior to cutaneous surgery because of the risk of thromboembolic stroke.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Brain Infarction; Carcinoma, Basal Cell; Drug Administration Schedule; Eyelid Neoplasms; Female; Humans; Male; Mohs Surgery; Postoperative Complications; Skin Neoplasms; Thromboembolism; Warfarin

This study was undertaken to determine if warfarin anticoagulation could be safely continued during surgery and in the perioperative period. An animal model was followed by a prospective human study of all patients on heparin or warfarin at the time of surgery. Twenty-four rabbits underwent laparotomy, during which a controlled liver injury was created and repaired. Group 1 (Warf) was anticoagulated with warfarin to raise the mean international normalization ratio (INR) to 2.5-3.0. Group 2 (Hep) was anticoagulated with heparin to raise the activated partial thromboplastin time to 1.5-2.0 times control. The heparin was then stopped 6 hr prior to surgery and resumed 6 hr postoperatively without a bolus. Group 3 (control) was not anticoagulated and received saline infusion. For the human study, data were collected on 40 patients undergoing 50 operations from October 1996 to January 1998. The results of this study reveal that (1) bleeding was less in the group anticoagulated with warfarin throughout surgery in the animal model, (2) bleeding complications were less in the patients continued on warfarin through surgery than those on heparin (3) older patients may have an increased risk of bleeding, and (4) an INR of >3 at the time of surgery may increase the risk of bleeding.

Topics: Animals; Anticoagulants; Blood Loss, Surgical; Female; Heparin; Humans; Incidence; Male; Middle Aged; Perioperative Care; Prospective Studies; Rabbits; Risk Factors; Time Factors; Warfarin

The purpose of the present work was to observe local hemostatic function during dental surgery in patients under oral anticoagulant therapy with an INR between 1.7 and 2.5. Thirty seven dental treatments were performed in 15 patients. Group A: nineteen dental treatments (13 scalings, 1 root canal therapy and 5 dental extractions), treated with oral rinse with tranexamic acid (250 mg dissolved in 10 ml of water). Group B: eighteen dental procedures (13 scaling, 1 root canal therapy and 14 dental extractions), in which oral rinse was utilized. Antibiotics were indicated for those patients with root canal therapy or with signs of infection. A cool soft diet was recommended to all patients during the three days following the surgical procedure. Only in five (13.5%) dental extractions (1 from group A and 4 from B) bleeding prolonged was observed, however periodontal disease was also present in those patients hone of them required blood products or withdrawal of the anticoagulant. The results suggest that mouth washing with tranexamic acid prevents excessive oral bleeding in patients treated with oral anticoagulants with an INR between 1.7 and 2.5.

Topics: Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Blood Loss, Surgical; Dental Scaling; Drug Evaluation; Gingival Hemorrhage; Gingivitis; Hemostasis, Surgical; Humans; Mouthwashes; Periapical Abscess; Periodontitis; Postoperative Hemorrhage; Root Canal Therapy; Tooth Extraction; Tranexamic Acid; Warfarin

Reexamination of surgical practices in the present era of cost containment has led to increased outpatient procedures including pacemaker surgery. While the safety and economic benefits of outpatient pacemaker surgery in nonanticoagulated patients is well documented, results of pacemaker operations in patients maintained on coumadin for thromboembolic prophylaxis have not been evaluated. In patients where complications with pacemaker surgery appeared successive, we have established a low incidence of complications. Recently, we extended this approach to the outpatient setting; this report retrospectively reviews our 4-year experience. During the study period, 150 patients underwent outpatient pacemaker procedures, including 37 patients receiving oral warfarin. There was no difference in the incidence of wound related and wound unrelated complications between patients receiving warfarin and the nonanticoagulated cohort. In addition, no wound hematomas, blood transfusions, or clinically significant bleeding episodes were noted among warfarin recipients. We conclude that pacemaker surgery in patients receiving oral anticoagulation is safe and feasible. The use of the cephalic cutdown technique avoiding blind subclavian punctures, meticulous attention to pocket hemostasis, and the use of small caliber unipolar positive fixation leads appears warranted in this selected group of patients at high risk for perioperative bleeding.

Topics: Administration, Oral; Adolescent; Adult; Aged; Aged, 80 and over; Ambulatory Surgical Procedures; Anticoagulants; Blood Coagulation Tests; Blood Loss, Surgical; Child; Child, Preschool; Cohort Studies; Cost Savings; Humans; Infant; Male; Middle Aged; New York City; Pacemaker, Artificial; Risk Factors; Warfarin

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Colonic Neoplasms; Emergencies; Heart Valve Prosthesis; Humans; Male; Postoperative Period; Warfarin

Many patients who undergo cutaneous surgery take medications that can affect bleeding. The role of these medications in postoperative bleeding complications is unclear. Dermatologists have no clear guidelines regarding the need to discontinue these medications preoperatively.. We designed a prospective study to evaluate the incidence of postoperative bleeding complications in patients taking aspirin, warfarin, or nonsteroidal antiinflammatory agents.. Data were collected from patients undergoing Mohs surgery regarding preoperative medication history, operative bleeding, and postoperative bleeding. Frequency of postoperative bleeding complications was then evaluated.. There was no statistically significant difference in postoperative bleeding complications between patients on aspirin, warfarin, or nonsteroidal antiinflammatory agents, when compared with controls.. It may not be necessary to discontinue aspirin, warfarin, or nonsteroidal antiinflammatory agents in patients undergoing many common dermatologic surgical procedures, such as Mohs surgery.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Bandages; Blood Loss, Surgical; Dermatologic Surgical Procedures; Evaluation Studies as Topic; Hematoma; Humans; Incidence; Medical History Taking; Mohs Surgery; Postoperative Hemorrhage; Practice Guidelines as Topic; Prospective Studies; Skin Transplantation; Surgical Flaps; Warfarin

To study the influence of preoperative warfarin anticoagulation on postoperative blood loss and allogeneic blood requirement.. Retrospective study with a matched control group.. University and community hospital, single institutional.. 240 patients scheduled for cardiac surgery.. Warfarin sodium was administered to 125 patients preoperatively to prevent thromboembolic complications of their underlying heart disease, 115 served as control. Approximately half of the patients in each group received aprotinin treatment during operation.. The international normalized ratio (INR) of the prothrombin time was preoperatively 2.4 (95% confidence interval [CI 0.95]: 2.3 to 2.6) in the warfarin group and 1.1 (CI 0.95: 1.0 to 1.1) in the control group (p < 0.05), and postoperatively 1.9 (CI 0.95: 1.8 to 2.1) (warfarin) and 1.5 (CI 0.95: 1.4 to 1.5) (control) (p < 0.05). The postoperative blood loss after 6 and 12 hours was 381 (CI 0.95: 329 to 434)/505 (CI 0.95: 439 to 571) mL (warfarin) compared with 472 (CI 0.95: 403 to 541)/612 (CI 0.95: 527 to 697) mL (control) (p < 0.05). This difference was blunted when the proteinase inhibitor aprotinin was used. Neither preoperative nor postoperative prothrombin time correlated with blood loss. Despite lower heparin consumption the activated coagulation time (ACT) during CPB was significantly prolonged in the warfarin group.. Warfarin pretreatment does not lead to increased bleeding but may even have a beneficial anticoagulant effect that may lead to better preserved postoperative hemostasis and reduced blood loss.

Topics: Aprotinin; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Case-Control Studies; Confidence Intervals; Female; Hemorrhage; Hemostasis, Surgical; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Premedication; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin; Whole Blood Coagulation Time

To measure the rate of decrease of the international normalized ratio (INR) after temporary discontinuation of warfarin therapy.. Prospective evaluation of an outpatient cohort.. University medical center anticoagulation clinic.. 22 patients receiving a fixed evening dose of warfarin for whom temporary discontinuation of therapy was deemed safe.. Serial plasma samples were drawn for INR measurements approximately 20, 65, 115, and 185 hours after patients received the last dose of warfarin. In five patients, INR was measured twice daily for 5 days.. For patients with a mean steady-state INR of 2.6, the mean INR 65 hours (2.7 days) after discontinuation of warfarin therapy was 1.6 (range, 1.11 to 2.16); 20 of 22 patients (91%) had an INR greater than 1.2. The mean INR 115 hours (4.7 days) after discontinuation of warfarin therapy was 1.1; 5 of 22 patients (23%) had an INR of 1.2 or greater. In 5 patients studied in detail, the INR decreased exponentially and had a half-life that ranged from 0.52 to 1.2 days; the onset of maximal decrease began 24 to 36 hours after discontinuation of warfarin therapy. In the total cohort, age was a significant (P < 0.005) independent predictor of smaller decreases in the INR between day 1 and day 3 (regression coefficient = -6.8% +/- 2%/2 days per decade of age; R2 = 0.34).. By simulating preoperative discontinuation of warfarin therapy, we found that the INR decreases exponentially, with wide interpatient variation in the rate of decrease. Age is associated with a slower rate of decrease. To be certain that the INR at the time of the surgery is less than 1.2, warfarin should be withheld for 96 to 115 hours (4 doses) in patients with a steady-state INR between 2.0 and 3.0. For patients with a higher steady-state INR, a longer wait is necessary.

Topics: Adult; Aged; Aged, 80 and over; Blood Loss, Surgical; Drug Monitoring; Elective Surgical Procedures; Female; Humans; Male; Middle Aged; Prospective Studies; Risk Factors; Time Factors; Warfarin

Topics: Anticoagulants; Blood Loss, Surgical; Cardiopulmonary Bypass; Humans; Plasma; Preanesthetic Medication; Vitamin K 1; Vitamin K Deficiency; Warfarin

The outcome of 50 surgical procedures in 41 patients who were anticoagulated at the time of surgery were reviewed to determine whether anticoagulation was associated with an increase in ophthalmic morbidity. Twenty-seven patients were receiving warfarin and 14 patients nicoumalone. The International Normalised Ratio (INR) was determined immediately prior to surgery and ranged from 1.1 to 4.9. Thirty-nine operations were performed under local anaesthetic and 11 under general anaesthetic. Thirty-three patients had extracapsular cataract extractions with posterior chamber lens implantation. No major haemorrhagic complications were associated with the local anaesthetic or the surgical procedure. Patients on anticoagulation therapy are at risk of life-threatening complications if their anticoagulation is stopped or reduced. This study demonstrates that most ophthalmic surgical procedures can be safely performed whilst the patient is therapeutically anticoagulated.

Topics: Acenocoumarol; Anticoagulants; Blood Loss, Surgical; Eye Diseases; Humans; Intraoperative Care; Prospective Studies; Thromboembolism; Warfarin

Hypothetical clinical cases were used to investigate transfusion-related decision-making. Three red cell, three fresh frozen plasma (FFP) and three albumin transfusion decision cases were administered by questionnaire to 228 medical staff. The transfusion decision triggers were identified and comparisons made between resident and specialist groups and between Melbourne and Sydney participants. Factors important in red cell transfusion decisions included haemoglobin, symptoms of anaemia, presence of co-morbidities or surgery, gender, period of hospitalisation and the degree of documented blood loss. FFP administration was influenced by an abnormal coagulation test, the presence of co-morbidities and by the number of red cell units transfused. The administration of albumin, concentrated or 5% SPPS, was influenced by the period of hospitalisation and clinical circumstances such as a falling urine output postoperatively, and by the presence of hypotensive complications. Different transfusion responses were noted: resident staff transfused red cells and FFP earlier than specialists; Sydney specialists were more conservative of red cell transfusion; Melbourne specialists more conservative of FFP administration and surgeons were four times more likely to transfuse patients than physicians or anesthetists at certain haemoglobin values.

Topics: Abruptio Placentae; Adult; Aged; Ascites; Blood Component Transfusion; Blood Loss, Surgical; Blood Transfusion; Cesarean Section; Colonic Neoplasms; Decision Making; Disseminated Intravascular Coagulation; Epistaxis; Female; Humans; Hypoproteinemia; Male; Medical Staff, Hospital; Middle Aged; Peptic Ulcer Hemorrhage; Plasma; Pregnancy; Serum Albumin; Sex Factors; Warfarin; Wounds and Injuries

The coagulation activity level at which oral surgery procedures can be performed in anticoagulated patients without triggering bleeding complications and without enhancing the risk of developing thrombo-embolic events remains controversial. The objective of the present study was to evaluate blood loss following dental extractions at different levels of anticoagulation and to determine its effect on wound closure rates. Blood loss was measured following the removal of four front teeth in warfarinized rabbits. Immediate blood loss was evaluated by determining the tooth socket bleeding times and by using a technique based on hemoglobin determinations. Long-term blood loss was assessed by comparison of labeled red-blood-cell disappearance curves. The results showed that blood loss following dental extractions was significantly greater in animals anticoagulated at a therapeutic level than in non-anticoagulated control animals. Determination of blood loss at different levels of anticoagulation clearly demonstrated that complete correction of the coagulation activity was unnecessary. Partial correction (INR values of 1.6-1.8) allowed extractions to be performed without extensive blood loss. With this technique of partial correction, the period of interruption of the anticoagulation could be kept very short, and the risk of postoperative bleeding complications was minimal. Wound closure rates were negatively influenced in anticoagulated animals.

Topics: Analysis of Variance; Animals; Bleeding Time; Blood Loss, Surgical; Chi-Square Distribution; Dental Care for Disabled; Rabbits; Tooth Extraction; Warfarin