VTE Unplugged Episode 4: Balancing Anticoagulation — Strategies for Surgical Management and Postoperative Complications in Thrombosis Patients
Now with the advent of or availability of scans in many of our hospitals, we are able to pick up pulmonary embolism more. So the incidence seems to be rising recently, but that's more because we were looking for it rather than assuming it has it was in the past. So suppose I've got a pulmonary embolism and for whatever reason the patient has a deranged parameter such as say thrombocytopenia. You already spoken to us about the liver dysfunction and kidney dysfunction. But in a pulmonary embolism is the intention of anticoagulation different and would you be worried about the thrombocytopenia and your original stank still sticks that you will go by the platelet count irrespective of the site of the thrombosis. Well so if someone has a progress to the point of having a pulmonary embolism, you know unconcerned and that is more scary to me than someone who has a lower shromney DDT because of the strain that it can put on the cardiovascular system. I will do a couple things. So a patient who has a PE with a platelet count under 50, I will start to be concerned. I will first look for the site of thrombosis. So if the patient still has lower extremity thrombosis, I will consider placing an IDC filter and then thinking if the thrombocytopenia is not going to get better. Otherwise if I think the thrombocytopenia short-lived, sepsis-induced or you know chemotherapy induced that will recover shortly, I may not do that. But if it's not reversible meaning essential thrombocytopenia that might be a patient that I go ahead and place an IDC filter in. Well then grade the type of PE they have. So a subsegmental PE, maybe incidental like you're saying, I'll treat very differently than a massive or submassive PE because basically if a patient is already developing right heart failure and they get more blockage either from propagation of the thrombosis or from a migration of a new thrombosis, that patient could die from this event. And so I will shift my treatment lower in those patients and I'll probably anticoagulate with a plate of the count of 40 and it might be low dose. I'll try to get prophylaxis even if I can't get treatment. So those were patients that I run a 10A level of maybe 0.3, a very very low 10A on IV, an IV happen rather than a 0.6 which is maybe what I would run in patients that I'm truly trying to treat. Okay, again I'm taking one last break. Question number 16, sorry question number 15, I think Dr. Shari is already answered that what are the criteria which enables you to choose a particular anticoagulate in high-risk. I think she's told us about liver, kidney, beautiful discussion. So I'm not going to repeat that question. So in a sense we've finished our question set as is Dr. Shari you want to bring out something for me a personal, you know, your practice because your hands on. So something that we haven't brought out that you feel we should have brought up? No I guess like I would like say and when you're ready for the closing comments just that I really feel that like yeah I was actually surprised to be candid about these questions because I don't think about giving prophylaxis very much. I give it to almost everyone all the time. I give it in the setting of renal failure. I've never thought about not giving it in the setting of renal failure. I give it in the setting of liver failure mostly, assuming the INR is not above three. I won't even check a tag, I still give it. So it's only when I get to the point where I get to treatment that I start considering not giving it. So that I guess was surprising for me. So I would like to share kind of how liberal I am with giving prophylaxis in these patients. And then you know we didn't touch on interventions or surgeries or anything like that. I'm not sure how applicable this is. It will impact my, you know, I guess site for central venous cannulation. I think about where people are bleeding, if I can compress it, I don't worry as much. Right? So if someone has a leg fracture and I can compress that or has, if I can see the site of bleeding, if they recently had surgery and I can see the site of bleeding in their leg, that's different than if they had, you know, something in their chest or something that I can't compress. So I don't know if we want to speak about those things, but those are things that I do think about. Thank you very much for all your comments, Dr. Shari. Now, you know, in our country liver diseases classified by the child's book, I did it into ABC. So does that help you to decide which anti-coevolution low molecular weight, low molecular weight heparin versus doax? So does it help you to choose between these anti-coevolutions? Yeah, I know I think that's a great question. We use the child's puke class as well in the MELDS4 and I think it kind of just helps me determine how sick the liver underlying is and how concerned I should be about the likelihood of something changing or the patient developing worsening failure. So in that case, if a patient is A, I think there's very little derangement in terms of a synthetic function and that the patient's still making some good coagulation factors. In that case, I don't spend that much time thinking about the liver failure in general. But if there are B or C, I think this makes me think a little bit more about if the patient's more likely to clot or more likely to bleed. And these are patients that I'm not going to reach for a doak and I'll probably reach for a heparin-based therapy. And we spoke a lot. Thank you. Thank you very much. You've got a patient of thrombosis. The patient is on an anticoagulant of the choice that was needed for the clinical situation. But there's now a need for surgery. So how should we go about stopping the anticoagulation so that we can have an uneventful surgery in terms of bleeding? Yeah. So I think this is a super important question and it comes a lot in a lot of patient populations like at thrombosis so we can think about a cancer patient that got a thrombosis, maybe at the time of presentation of their original cancer, and then now has undergone chemotherapy or had gone to the point where they can actually get us some sort of resection. But they're still within that three month period and delaying the therapy until after that initial three month treatment period is inappropriate. So in that case, we will give, I will work with the patient and the surgeon to kind of do a true bridge. So if the patients are far enough out and are going to be terminated from the anticoagulation for less than 24 hours and I don't think there's a super elevated thrombosis risk, meaning the other one was provoked. I will bring the patient in, put them on a heparin drip, turn it off right before the surgery and then undergo the surgery. If the surgery, maybe it's guillotine or something that can quickly, that I could observe the bleeding, very low bleeding risk after it happens and we could resume within 24 hours. Now if the patient does not and or the surgeon does not think that they can tolerate with an anticoagulation within 24 hours, those will be patients that I think about putting an IVC filter in prophylactically. So I will still continue into coagulation up into the point of surgery, but I will place an IVC filter within 24 to 48 hours prior to surgery. I will then undergo the surgery, hold the anticoagulation for as long as I need for the surgery and then remove the IVC filter one week after I feel like the bleeding risk is done. The one week is a guideline that's not set in stone, but I'd like to have a short follow up for that so that I can be sure that it gets removed because any IVC filter is a night is for thrombosis when not an anticoagulation or even can be catastrophic if it does per freight through the IVC. I will say that there are new chest guidelines peri-op chest guidelines coming out within the next year, which we should all be open to and look for because I think that exactly what you're saying, this is very difficult. It's a very nuanced discussion. It needs to be with both the patient, the surgical team and it needs to be a very thought out process. Thank you for that, Bill. I'm sure all of us will look forward to those guidelines because this is the vexing issue for most of us. But what if the same patient after the surgery now develops a deranged parameter? It was renal or liver or drops the platelets, post-op patients, and a seizure colleagues about what happened during the surgery. It was a little bit more bloody for whatever reason. That could be a case where I will put in the IVC filter early or if they say that in general the patient was more bleedy or had more neovascularization or something that was causing them to think that this is going to be a delayed healing. If the surgeon said the case was totally normal and I'm surprised, I think this will stop soon, I will be a little bit more, I'll maybe slow play it a little bit more. I'll initiate again that low dose heparin prophylactic, almost dosing at 0.3, tenet, and watch the patient. I will transfuse as needed, assuming that I don't need to give more than a unit every other day, I might even treat a little bit more because I think that the risk of thrombosis is so high in this patient. There's a lot of different surgeries, spine surgery, there are a lot of different things that there are big caveats, because a little bit of blood in a spinal space is very different. A little bit of blood in an abdominal space. This is a huge, huge body of literature. I'm not trying to say one size fits all. I think the take home message is it needs to be individualized by the patient, it needs to be communicated with the surgeon and the anesthesia team about what happened and what they think. Then there needs to be frequent monitoring in order to develop a good plan and IVT filter might be part of the plan with a short term removal. Beautiful, what we're trying to tell is that it's going to be a very case to case discussion for which there might be difficulty in putting a guideline, but our awareness about the pros and cons of anti-quagulation and selection is extremely important. Hence, this podcast will help us to be more aware of our options. So Dr. Shari, Bra Thank you so much. You've been brilliant. You patiently answered all our questions in helping us making the right choice where we've got patients who are either bleeding or clotting and you also help us to analyze how to approach anti-quagulation, be it prophylactic or therapeutic in patients with special situation where there are deranged parameters. So that was just brilliant. Thank you very much. But I'm not going to let you go till you give us some pearls of wisdom at the end so that we can be even wiser at the end of this podcast. Thank you so much. Thank you so much. I very much enjoyed my time and I feel like we've had such a great discussion. We brought up so many amazing topics that are just hard for us to, we think we know about anti-quagulation and then we actually go through scenarios and it can be a lot harder than we think. I would leave us with the idea that prophylactic anti-quagulation in general can be very, very safe in most patients even with deranged parameters. I think the one that I worry about most is thrombocytopenia but I tend to not worry about renal failure and I do get slightly concerned about liver failure but I'm not sure you can't make a universal rule about cirrhosis at all. It can do a lot of different things parameters and so do not take the INR as fact by any means. But I would, the last point that I want to make is that we don't want to ever be the source of something bad happening to our patients. We never want to make them bleed but by not giving patients prophylaxis we might inadvertently make them clot. And so we need to remember inaction can be as problematic as action and so if you think your patient qualifies by using any of these structured bleeding scores and clotting scores you should give the patient anti-quagulation prophylactically. Thank you very much Dr. Shari, that was brilliant, thanks. Thank you.
