John is having elective surgery next month. He's referred to your perioperative clinic. He's on medications for diabetes and blood thinners.
What would you do? Open this thread and I'll share my approach.
#MedEd @MedTweetorials
#MedTwitter #MedStudentTwitter
@aoglasser
What would you do? Open this thread and I'll share my approach.
#MedEd @MedTweetorials
#MedTwitter #MedStudentTwitter
@aoglasser
Firstly, this thread is intended for medical education and is not clinical advice
A person needs adequate reserves to tolerate an operation.
You need a performance status of >4 METS (metabolic equivalents) which is the equivalent of walking up a flight of chairs.
A person needs adequate reserves to tolerate an operation.
You need a performance status of >4 METS (metabolic equivalents) which is the equivalent of walking up a flight of chairs.
Next some general rules on dealing with blood thinners. Surgeons may request they be ceased prior to the surgery.
- Stop aspirin 5 prior
- Clopidogrel 7 days prior
- Ticagralor 5 days prior
Discuss coronary stents with the cardiologist about the risk of holding antiplatelets.
- Stop aspirin 5 prior
- Clopidogrel 7 days prior
- Ticagralor 5 days prior
Discuss coronary stents with the cardiologist about the risk of holding antiplatelets.
If your patient is on warfarin then assess whether they need bridging anticoagulation while you hold the warfarin.
Bridging is indicated for:
- Mechanical valves
- High CHADSVaSc score (5-6)
- VTE/Stroke within 3 months
Bridging is indicated for:
- Mechanical valves
- High CHADSVaSc score (5-6)
- VTE/Stroke within 3 months
The rule of thumb for bridging is to:
- Stopping warfarin 5 days before the procedure
- Therapeutic enoxaparin from 3 days before and stop 24 hours before
- Stopping warfarin 5 days before the procedure
- Therapeutic enoxaparin from 3 days before and stop 24 hours before
If you're holding warfarin, check the INR 5-7 days before the procedure:
- If <2 stop warfarin 3-4 days before
- If 2-3 stop 4 days before
- If >3 stop 5 days before
Irrespective of the path you take, recheck the INR within 24 hours of the procedure.
- If <2 stop warfarin 3-4 days before
- If 2-3 stop 4 days before
- If >3 stop 5 days before
Irrespective of the path you take, recheck the INR within 24 hours of the procedure.
For direct oral anticoagulants (DOACs), the duration of holding is often somewhere between 24 and 72 hours but depends algorithms based on:
- Renal function (marker of clearance)
- Bleeding risk of the operation
Neurosurgery and urology have particularly high bleeding risks
- Renal function (marker of clearance)
- Bleeding risk of the operation
Neurosurgery and urology have particularly high bleeding risks
For those with diabetes...
Metformin:
- hold day of surgery
- risk of lactic acidosis
SGLT2 inhibitors
- stop 2 days before procedure
- risk of euglycaemic ketoacidosis
Insulin:
- First on the operating list
- Hold regular and start insulin infusion at 10am or induction
Metformin:
- hold day of surgery
- risk of lactic acidosis
SGLT2 inhibitors
- stop 2 days before procedure
- risk of euglycaemic ketoacidosis
Insulin:
- First on the operating list
- Hold regular and start insulin infusion at 10am or induction
In summary, for perioperative patients consider:
- Performance status
- Blood thinners including antiplatelets and warfarin
- Bridging enoxaparin for those at high risk
- Hold antihyperglycaemic agents +/- insulin infusion
- Performance status
- Blood thinners including antiplatelets and warfarin
- Bridging enoxaparin for those at high risk
- Hold antihyperglycaemic agents +/- insulin infusion
If you found this thread helpful, please retweet so others can find it.
I'm releasing new tweetorials weekly. Follow me today so you don't miss out on future threads!
I'm releasing new tweetorials weekly. Follow me today so you don't miss out on future threads!
Until then, here's another thread on assessing multimorbid medical patient in clinic
Loading suggestions...