Clexane Bridging in the Anaesthetic Preassessment Clinic

Clexane Bridging in the Clexane Bridging in the Anaesthetic Preassessment Anaesthetic Preassessment ClinicClinic

Dr Paul Sice, Consultant Anaesthetist

Derriford Hospital, Plymouth

ObjectivesObjectives

The problems with the old system

The development of the new guideline

The clexane bridging pathway

The practicalities of making it work

Examples

The Old SystemThe Old System

Evidence-based

Douketis JD, Johnson JA, Turpie AG. Low-molecular

weight Heparin as bridging anticoagulation during

interruption of Warfarin. Arch Int Med. 2004; 164: 1319 – 26.


Risk assessment

Acute (within 6 weeks) arterial or intra-cardiac thrombosis1 Very high risk: Full LMWH bridging essentialExpert opinion recommended

Recurrent arterial thrombosisMechanical prosthetic heart valveRheumatic atrial fibrillation

High risk: Full LMWH bridging

Non-rheumatic atrial fibrillationDilated cardiomyopathy or LV aneurysm

Moderate Risk Standard Thromboprophylaxis: low dose LMWH

Acute (within 6 weeks) venous thrombosis1

Recurrent venous thrombosis whilst on warfarin therapy2

Recent (within 3 months) venous thrombosis + high risk surgery3

Very high risk: Full LMWH bridging essentialExpert opinion recommendedConsider IVC filter

Recent (within 3 months) venous thrombosisHistory of recurrent venous thrombosis + high risk surgery3

High risk: Full LMWH bridging

Single previous venous thrombosis (> 3 month)Known thrombophilia or malignant disease

Moderate Risk Standard Thromboprophylaxis: low dose LMWH


Clear Instructions

Check INR 1 week before planned surgery:

a.INR 1.5 – 2.0: stop warfarin for 3 full days pre-operatively.

b.INR 2.0 – 3.0: stop warfarin for 4 full days pre-operatively.

c.INR 3.0 – 4.0: stop warfarin for 5 full days pre-operatively.

d.INR < 1.5 or > 4.0: seek expert advice.

1.Check INR daily once warfarin stopped.

2.Start LMWH as soon as INR is 2.0 or less.

3.Recommended dose of enoxaprin (Clexane) is 1.0 mg/kg bd

4.Last preoperative dose should be given …18 - 24 hours pre-surgery

5.Restart Clexane 12 – 24 hours post op. (in absence of active bleeding)

6.Restart warfarin at previous maintainance dose on 1st postoperative day.

7.Check INR daily.

8.Stop Clexane when INR in therapeutic range for 2 consecutive days.

The Old System - The Old System - DifficultiesDifficulties

More disparate surgical pre-assessment

Day of surgery admission

Clinicians doing their own thing

Some impractical parts of the protocol



a.INR 1.5 – 2.0: stop warfarin for 3 full days pre-

operatively.

b.INR 2.0 – 3.0: stop warfarin for 4 full days pre-

operatively.

c.INR 3.0 – 4.0: stop warfarin for 5 full days pre-

operatively.


Giving people a choice









Blood testing difficult









3.Recommended dose of enoxaprin (Clexane) is 1.0 mg/kg bd

4.Last preoperative dose should be given …18 - 24 hours

pre-surgery

Potential for mistakes and variation

Geography (patient journeys)Geography (patient journeys)

New DevelopmentsNew Developments

Pre-assessmentClinic

General

ENT

etc

Surgical specialties

Orthopaedics Pre-assessment

Waiting List ? Day of Surgery

The WorkloadThe Workload

Review of Clinic Records – 10 weeks

353353 60 CPX46 ECG check

247247

Warfarin DecisionsWarfarin Decisions

4444 20%20%

A New GuidelineA New Guideline

Evidence Based

Minimise Patient Journeys

Accommodate New policy

Patient Safety

Simple as Possible

The Perioperative Management of Antithrombotic Therapy

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

James D. Douketis, MD, FRCP(C); Peter B. Berger, MD, FACP; Andrew S. Dunn, MD, FACP; Amir K. Jaffer, MD; Alex C. Spyropoulos, MD, FACP, FCCP; Richard C. Becker, MD, FACP, FCCP and Jack Ansell, MD, FACP, FCCP

1. Chest. 2008; 133:299S-339

Latest EvidenceLatest Evidence

Decision-Making PathwayDecision-Making Pathway1. Is the surgeon willing to operate on warfarin?

Continue. Check INR is within required limits

2. Does the patient require clexane bridging? (See risk assessment)

Heart Valve High Risk Any mechanical valve Therapeutic 1mg/kg BD

AF: CHADS2 Score: (1

for each except CVA /TIA)Cardiac failure **HypertensionAge >75DiabetesStroke TIA(Stroke or TIA at any time scores 2)

High risk CHADS2 >4. CVA/TIA < 3/12 Therapeutic 1mg/kg BD

Mod. Risk CHADS2 >2 Prophylactic 40mg SC OD

Low Risk CHADS2 of 0-2. No previous

CVA/TIA. Normal heart

No Clexane

Venous Thrombo-Embolism

Mod. To High Risk

VTE within 1 year. Recurrent VTE. Severe thrombophilia

Therapeutic 1mg/kg BD

Acute thrombosis within 6 weeks or whilst taking Warfarin: Seek specialist advice

Stroke Mod. Risk Warfarin for recurrent CVA Prophylactic 40mg SC OD

Cardiac Failure Mod. Risk Cardiomyopathy, LV aneurysm, cardiac failure

Prophylactic 40mg SC OD

Yes

No

Yes

Decision-Making PathwayDecision-Making Pathway

Stop warfarin 5 days before surgery1

Prophylactic clexane

Therapeutic clexane

1. Chest. 2008; 133:299S-339

Yes

No clexane

Clexane BridgingClexane Bridging

Safety (therapeutic bridging)

Blood testing (INR)

Days prior to surgery

5 4 3 2 1 Day of Surgery

Omitting Warfarin Omit

Giving Clexane

Prophylactic ClexaneProphylactic Clexane

Days before surgery

5 4 3 2 1

Stopping Warfarin

Omit

When to take clexane injections (TICK)

08:00 18:00

40mg OD

Therapeutic ClexaneTherapeutic Clexane

Arterial Risk Factors

Venous Risk Factors

1mg/kg BD

Days before surgery

5 4 3 2 1

Stopping Warfarin

Omit


08:00 18:00 Omit Clexane

? 1.5mg/kg OD

Atrial FibrillationAtrial Fibrillation

CHADS2 Score: (1 for each

except CVA /TIA)

Cardiac failure **HypertensionAge >75DiabetesStroke TIA

(Stroke or TIA at any time scores 2)

High risk CHADS2 >4.

CVA/TIA < 3/12



Low Risk CHADS2 of 0-2.

No previous CVA/TIA.

Normal heart

No Clexane

Important Safety Points Important Safety Points

Renal failure – eGFR < 30

Therapeutic dosing with 1mg/kg OD am only

Only 40mg the day before surgery

Use lean body weight

Days before surgery

5 4 3 2 1

Stopping Warfarin

Omit


08:00 40mg 18:00



Body weight (low and high)

ProphylaxisProphylaxis

20mg OD if < 50kg20mg OD if < 50kg

BMI >= 35BMI >= 35

? Lean body weight? Lean body weight



Body weight (low and high)

Anti factor Xa levels

The PracticalitiesThe Practicalities

Self injectingSelf injecting

Patient InformationPatient Information

Linking with the Linking with the communitycommunity

Decision-Making 2Decision-Making 2

YesYes

Nurses can teach the patient or relative

Patient picks up clexane prescription from hospital

Patient information sheet

Can the patient Can the patient self-inject?self-inject?

Self injectingSelf injecting

Decision-Making 2Decision-Making 2

NoNo

Patient picks up clexane prescription from hospital

Patient information sheet

PCT Community prescription

Can the patient Can the patient self-inject?self-inject?

Telephone GP PracticeTelephone GP Practice

Community Input Community Input

Pre-assessment

Acute GP service

Surgical assessment unit

Carefully plan day of surgery

Practice can helpPractice can help

Practice can’t helpPractice can’t help Patient can’t getPatient can’t gettherethere Bridging over W/EBridging over W/E




Any Other Pre-op instructions

Remember not to take your insulin on the morning of the operation when you have nothing to eat

Take your blood pressure tablets as usual.

Example 1Example 1

49 yr old man. Needs a cystoscopy

Dilated cardiomyopathy, EF 40%, valves ok

AF on warfarin (stable INR)

TIA 3 years ago

Internal cardiac defibrillator

Front of list

85kg, normal renal function


AF: CHADS2 Score: (1 for

each except CVA /TIA)Cardiac failure **HypertensionAge >75DiabetesStroke TIA(Stroke or TIA at any time scores 2)





No Clexane

Venous Thrombo-Embolism Mod. To High Risk







Wife will inject clexane

Prophylactic clexane 40mg s/c

Prescription and information sheet

Example 2Example 2

85 year old lady 80 kg

Needs cervical disc surgery

Chronic renal failure eGFR 25

Warfarin for recurrent DVT and PE

Wheelchair due to pain but husband mobile. No car.

Front of list








No Clexane








e GFR <30e GFR <30Clexane 1mg / kg OD40 mg day before surgeryPrescription and information sheet

80mg 80mg 40mg

PracticalitiesPracticalities

Feel they can’t cope with clexane injections

GP practice know them well. Husband can push the wheelchair. Practice nurses happy to inject clexane.

Clexane prescription, information leaflet and PCT prescription

Patient will let practice know when she has a date and take paperwork to sort out plan

Extreme BridgingExtreme Bridging

Example 3Example 3

80 year old lady. 40kg. Lives alone

Needs lumbar spine surgery

Warfarin for mechanical mitral valve

INR unstable at times

Lives in Plymouth, has to get the bus to hospital

Surgery scheduled for Tues (bridging a w/e)

Worried about self-injecting








No Clexane








Therapeutic clexane 40mg BD

Prescription and information sheet

omit

40mg40mg

PracticalitiesPracticalities

Worried about clexane injections

GP practice isn’t available over the weekend

Unfair to get bus BD over the weekend

What other option do we have?

Thank you, any questions?Thank you, any questions?

Documents

Clexane Bridging in the Anaesthetic Preassessment Clinic