Contraindications to Time Critical Surgery;

when not to proceedThe Anaesthetic perspective

Time Critical SurgeryEmergency; arising unexpectedly and requires immediate action

Urgent; quick but not immediate action within 24 hours

Emergent; Beginning to arise ( Few hours)

Elective. L King. The Rubric Theme. Jan 2013

Indicated Surgery where delay will act as a negative predictor on patient outcome

Time Critical SurgeryEmergency; arising unexpectedly and requires immediate action

Urgent; quick but not immediate action within 24 hours

Emergent; Beginning to arise ( Few hours)

Elective. L King. The Rubric Theme. Jan 2013

Indicated Surgery where delay will act as a negative predictor on patient outcome

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Palliative Carevs

‘Heroic’ Surgery

AAACardiac TamponadeAortic Dissection Type 1

Haemorrhage

Ischaemic legSeptic AbdomenRuptured ViscusSubdural

HypoxiaInability to Ventilate - Asthma

ShockIngested Toxin

Metabolic - Ketoacidosis

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Proceed Maximal Anaesthetic

Intervention

AAACardiac TamponadeAortic Dissection Type 1

Haemorrhage

Ischaemic legSeptic AbdomenRuptured ViscusSubdural

Valvular heart DiseasePulmonary HypertensionLeft main DiseaseLeft ventricular failureLactic AcidosisMyasthenia

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Cancel

Carcinoma AnneurysmsIntracranial tumorsUnstable fracturesInfections requiring drainage

HypoxiaInability to Ventilate - Asthma

ShockIngested Toxin

Metabolic - KetoacidosisEndocrine- thyrotoxicosis

-phaeochromocytoma

Time Critical

Life threateningAnaesthetic

Clinically Based. ICU emergency.

Supply Oxygen; ARDS maximal ventilator settings. FiO2 100%, High PEEP, Desaturations, Difficult transportation.Bronchopneumonia.Severe Asthma. Accessory muscle use, tiring, sitting up.

Deliver Oxygen Shock.

Utilize Oxygen - CN

Metabolic. Ketoacidosis, Ingested Toxin

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Valvular heart DiseasePulmonary HypertensionCoronary Artery/Left main DiseaseLeft ventricular failureMyastheniaHepatic FailureRespiratory Failure

Carcinoma AnneurysmsIntracranial tumorsUnstable fracturesInfections requiring drainage

CancelResolve

Delay

Proceed

Cancel

Resolve

Delay

Proceed

Risk

Benefit

Clinician ExperienceRisk IndicesBiochemical Markers

Cardiac Risk Indices

• Goldman Risk Index 1970

• Detsky’s (AS, VE’s, Surgery) 1986

• Eagles (Vascular, Thallium imaging) 1989

• Lee’s Revised Risk Index (RCI) 1999

• ACA/AHA Cardiac Risk Classif. 2007

• STS, Frailty, Major organ system dysfunction, procedure-specific impediments for Valve Surgery.

2014

Cardiac Risk Indices

• Goldman Risk Index

• Eagles

• Detsky’s

• Lee’s Revised Risk Index (RCI)

• ACA/AHA Cardiac Risk Classification.

RCI CATEGORIES • High-risk surgery (intrathoracic, intra-abdominal. or

suprainguinal vascular) • Ischemic heart disease (defined as a history of MI,

pathologic Q waves on the ECG, use of nitrates, abnormal stress test, or chest pain secondary to ischemic causes)

• Congestive heart failure • History of cerebrovascular disease • Diabetes requiring insulin therapy • Preoperative serum creatinine level higher than

2Â mg/dLNumber of Factors Risk I 0.4% 2 1% 3 7% 4 11%

2014 AHA/ACC guideline for the managment of patients with valvular heart disease . Nishimura et al. J Thoracic and Cardiovascular Surgery. 2014 148 1 99-103.

Seven Frailty indices:1. Katz Activities of Daily living. (ADL) 6 = Full Function, <2 Severe impairment

Feeding, Bathing, Dressing, Transferring, Toileting, Urinary continence.

2. Independence in ambulation; Walking aid, or not, 5 meter walk in < 6secondsText

Risk Assessment Valve Surgery 2014 AHA/ACC Guidelines

.STS, STS database Online Calculator

Frailty IndexMajor Organ System Dysfunction Procedure Specific Impediments

Smetana G W et al. Ann Intern Med 2006;144:581-595

Patient Risk Factors for Postoperative Pulmonary Complications

Recent cessation of Smoking OR 6.7 ASA 2+ Status OR 4.8Surgical Site - thoracic OR 4.24 Increasing age OR 3CCF OR 2.93Surgical length OR 2.26 Emergency Surgery OR 2.21 Impaired Sensorium - delerium OR 1.39Anaesthesia OR 1.83

Predictors of Postoperative ARDSPreoperative Predictor OR

ASA 3-5 18.96Emergent Surgery 9.34

Renal Failure 2.19COAD 2.16

Number of Anaesthetics/admission 1.37Male 1.65

Intraoperative RBC transfusion 5.36

Crystalloid transfusion 1.43Ventilator drive pressure 1.17

Preoperative and Intraoperative Predictors of Postoperative AcuteRespiratory Distress Syndrome in a General Surgical Population. Blum J et al. Anaesthesiology 2013,118(1),19-29

2. MELD Classification >15 Cancel ‘Elective’3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43×aetiology(0:

cholestatic or alcoholic, 1: otherwise) Se BIlirubinSe CreatinineINRAetiology of Liver disease"

Meld Mortality %

40+ 71.3

30-39 52.620-29 19.610-19 6

<9 1.9Wiesner et al. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology (2003) vol. 124 (1) pp. 91-6

In Hospital 3mth Mortality

Monitoring and managing hepatic disease in anaesthesia D. Kiamanesh, J. Rumley and V. K. Moitra* British Journal of Anaesthesia 111 (S1): i50–i61 (2013)

1. Pugh Classification Grps B, C - 12% mortality in Abdominal Surgery

Liver Disease

3. MELD plus Na

Online CalculatorsHepatic Failure

MELD liver disease

Heart scoreRCI cardiac risk

STS

Intensive Care admissionModified Early warning Score (MEWS)

Respiratory assessmentPneumonia Severity Index. PSI

CURB-65 severity score for community acquired pneumonia; confusion, age>65, BUN, RR. Need for intubation

MD Calc

Biochemical Marker Risk Assessment

pg/ml MACE % Death % OR

0-29 1.2 0

30-115 6.5 2.8 5.6

116-372 20.9 5.5 21

>372 36.7 12.2 45.5J Am Coll Cardiol, 2011; 58:522-529,

BNP levels in predicting Major Adverse Cardiac Event (MACE)at 30D

Anaesthesiology 2013;119:270-83

Anaesthesiology 2013;119:270-83

Anaesthesiology 2013;119:270-83

ROC calculationPostoperative point was

BNP 245pg/ml (ROC 0.71 95%CI 0.64-0.78)

NT-proBNP 718pg/ml (95% CI 656-995pg/ml)

Merged 0.76 95% CI 0.73-0.80.

Anaesthesiology 2013;119:270-83

Life threatening Major Risk

Emergency

Time Critical

Anaesthetic

Surgery

Valvular heart DiseasePulmonary HypertensionCoronary Artery/Left main DiseaseLeft ventricular failureMyastheniaHepatic FailureRespiratory Failure

Carcinoma AneurysmsIntracranial tumorsUnstable fracturesInfections requiring drainage

CancelResolve

Delay

Proceed

Coronary Artery Disease

Coronary Artery Disease

?

Non Cardiac Surgery following Cardiac intervention

3-4 weeks 2-3 months

PCI CABG PCI CABG

Mortality 26% 1-4 21%5 <1%1-4 3.9%5

MI 35% 5%1. Sharma AK, Ajani AE, Hamwi SM et al. Major noncardiac surgery following coronary stenting: when is itsafe to operate? Catheterization and Cardiovascular Interventions 2004; 63: 141–14539. Kaluza GL, Joseph J, Lee JR et al. 2.Catastrophic outcomes of noncardiac surgery soon after coronarystenting. Journal of the American College of Cardiology 2000; 35: 1288–1294.3. Posner KL, Van Norman GA & Chan V. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty. Anesthesia and Analgesia 1999;89: 553–560.4.Wilson SH, Fasseas P, Orford JL et al. Clinical outcome of patients undergoing non-cardiac surgery in thetwo months following coronary stenting. Journal of the American College of Cardiology 2003; 42: 234–240.5. Breen P, Lee JW, Pomposelli F & Park KW. Timing of high-risk vascular surgery following coronary artery bypass surgery: a 10-year experience from an academic medical centre. Anaesthesia 2004; 59: 422–427.

Coronary Revascularisation • Revascularisation pre surgery vs maximal

medical therapy (b-Blocker, Statin, Aspirin) outcome no different

Godet G, Riou B, Bertrand M et al. Does preoperative coronary angioplasty improve perioperative cardiacoutc ome? Anesthesiology 2005; 102: 739–746.McFalls EO, Ward HB, Moritz TE et al. Coronary artery revascularization before elective major vascularsurgery. The New England Journal of Medicine 2004; 351: 2795–2804.

• Half Postoperative MI occur in areas of non significant stenosis.

Dawood MM, Gupta DK, Southern J et al. Pathology of fatal perioperative myocardial infarction: implications regarding physiopathology and prevention. International Journal of Cardiology 1996; 57: 37–44.Landesberg G. The pathophysiology of perioperative myocardial infarction: Facts and perspectives. Journal of Cardiothoracic and Vascular Anesthesia 2003; 17: 90–100.Le Manach Y, Perrel A, Coriat P et al. Early and delayed myocardial infarction after abdominal aorticsurgery. Anesthesiology 2005; 102: 885–891.Giroud D, Li JM, Urban P et al. Relation of the site of acute myocardial infarction to the most severecoronary arterial stenosis at prior angiography. The American Journal of Cardiology 1992; 69: 729–732.

Coronary Artery DiseaseThe Surgery cannot wait 24hours.

The risk of PCI or CABG greater than Surgery proposed with “Maximal Medical Protection” - (B Blockade, Statins, AP therapy)

Echo:LV functionValvular pathology

Proceed

Coronary Artery Disease

The “Time critical” surgery can wait 2-3 months.

Indicated if High level proximal stenosis, large area of myocardium affected.

Unstable plaque

BMS, 4-6weeks, ? Double AP therapy

Resolve

Coronary Artery Disease

The “Time critical” surgery can wait 2-3 weeks

? Opinion for the Role of Isolated coronary Dilatation without stent.

Opinion Delay

Nothing to offerCath Lab

ProceedDelayEcho:

LV functionValvular pathology

Non Cardiac Surgery and Balloon Angioplasty

Surgery within 60 daysn = 345

Surgery within 14 daysn=188

Mortality 0.3% 0.5%

MI 0.6% 1%

1. Brilakis ES, Orford JL, Fasseas P et al. Outcome of patients undergoing balloon angioplasty in the twomonths prior to noncardiac surgery. The American Journal of Cardiology 2005; 96: 512–514.2. Agostini P, Biondi-Zoccai GGL, Gasparini GL et al. Is bare-metal stenting superior to balloon angioplastyfor small vessel coronary artery disease? Evidence from a meta-analysis of randomized trials. EuropeanHeart Journal 2005; 26: 881–889.

Valvular Heart disease

Valvular Heart diseaseAortic Stenosis.

Un-Diagnosed AS and Non-Cardiac surgery - Comps 10-30%

Arrhythmias esp AF or SVT

Diastolic Dysfunction, filling and perioperative fluid use.

Systemic hypotension

Preoperative medications may need to be continued - Diuretics

2014 AHA/ACC guideline for the managment of patients with valvular heart disease . Nishimura et al. J Thoracic and Cardiovascular Surgery. 2014 148 1 99-103.

Mitral Stenosis.LV Failure - “Can the patient lie flat”

Anaesthesia reduces systemic vascular resistance, tachycardia reduces LV filling and coronary perfusion and is associated with arrhythmias and large fluid shifts.

Aortic Stenosis and Non-Cardiac Surgery:Managing the Risk. S Pislaru et al Curr Probl Cardiol. 2015. In press.

Severe AS - Mortality no different to matched Controls

- Increased Cardiovascular morbidity (MI CHF)18.8% AS vs 10.5% Matched Controls n=256 Mayo 2000-10 -Independent predictors AF, Cr>2mg/dl, Emergency Sx

Aortic Stenosis and Non-Cardiac Surgery:Managing the Risk. S Pislaru et al Curr Probl Cardiol. 2015. In press.Aortic valve stenosis in community medical practice: determinants of outcome and implications for Aortic valve replacement. J Thorac Cardiovascular Surg; 144(6):1421-7

Symptoms at Diagnosis of AS - Frequent and Unrelated to severity.

Aortic Stenosis and Non-Cardiac Surgery:Managing the Risk. S Pislaru et al Curr Probl Cardiol. 2015. In press.

Aortic Stenosis and Non-Cardiac Surgery:Managing the Risk. S Pislaru et al Curr Probl Cardiol. 2015. In press.

Balloon Valvuloplasty Average increase in valve area 0.6 to 0.9cm2, improved symptoms and ‘may’ improve haemodynamics.Case series 15 unsuitable for TAVI (Mayo 1989) Hayes et al

- 1 death due to VT, 4 Complications.7 Roth (1989)7 Levine (1988)reports in pregnancy, cancer, liver transplantation.

Level C Evidence 2014 AHA/ACC guidelines Nishimura et al. J Thoracic and Cardiovascular Surgery.

Mitral Stenosis

TTE for assessment of severity and anaesthetic planning

MS difficult for Anaesthesia.

‘Heart ValveTeam’ review

Consider percutaneous balloon commissurotomy.

‘Maintain preload high enough to allow an adequate forward cardiac output across the stenotic valve but low enough to avoid pulmonary oedema’ (Level C)

Resolve

VHA recomend valve morphology not favourable for balloon -

Pulmonary Hypertension and non-cardiac surgery

Pulmonary hypertension: An important predictor of outcomes in patients undergoing non-cardiac surgery. Roop Kaw et al. Respiratory Medicine. 2011,105,619-624.

Cleveland Clinic experience.

Pulmonary Hypertension and non-cardiac surgery

Pulmonary hypertension: An important predictor of outcomes in patients undergoing non-cardiac surgery. Roop Kaw et al. Respiratory Medicine. 2011,105,619-624.

1. Cleveland Clinic experience.

PH No PH

MPAP mmHg 37.3+8 17.4+4

PCWP mmHg 20.8+7.5 11.2+4.6

PVR Wood U 3.3+2.1 1.2+0.8

2. Mortality 7-9.4% Ramakrishna G et al J am Coll Cardiol 2005;45(10): 1691-9,

Lai HC et al. Brit J Anaesth 2007;99(2):184-90

Pulmonary Hypertension and non-cardiac surgery

Preoperative Expert physician involvement “Pulm Hypertensionists”Intraoperative

Appropriate Site, - Time, Anaesthetic supportMonitoring; - PA Catheter, Echo,Specialised intervention - Inotropes, NO, milrinone, prostaglandins IABP. Sudenafil

Postoperative support. ICU to actively treat CHF.

Now You can do the operation.

Delay

Is this an appropriate site?

Is this an appropriate time?

Skill set.

Support.

Resolve

Dual Antiplatelet therapy

?

HighLow

High Bleeding Risk

Low Bleeding Risk

Thrombosis Risk

Surgery

Dual Platelet Therapy and Surgery

DAPT - Bleeding RiskPlastics Moh Procedure. Complications 8x more likely on DAPT

Vascular surgery n=647 no increased bleeding or transfusion Increased haematoma in carotid surgery10,406 vascular (carotid , lower extremities, AAA, Stent) no increased transfusion, reoperation, bleeding

Thoracic No increased risk. One report increased transfusion

Orthopaedic Major joint but not NOF increase bleeding and transfusion

Urology TURP increased risk

Intra abdominal ‘Safe’

Cardiac Increased bleeding Reoperation rate 1.6 to 9.8%,

Transfusion 51% vs 73% and Blood Units 1.6 vs 3.0

Perioperative management of antiplatelet therapy A. D. Oprea* and W. M. Popescu Br. J. Anaesth. (2013) 111 (suppl 1): i3-i17.

Harrington RA, Becker RC, Ezekowitz M et al. Antithrombotic therapy for coronary artery disease: theSeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 supplement): 513S–548S.Popma JJ, Berger P, Ohman EM et al. AntithromboticYusuf S, Zhao F, Mehta SR, et al, CURE Trial Investigators. Effects of clopidogrel in addition to aspirin inpatients with acute coronary syndromes without ST-segment elevation. The New England Journal of Medicine 2001; 345: 494–502.

Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.

DAPT - Bleeding RiskPlastics Moh Procedure. Complications 8x more likely on DAPT

Vascular surgery n=647 no increased bleeding or transfusion Increased haematoma in carotid surgery10,406 vascular (carotid , lower extremities, AAA, Stent) no increased transfusion, reoperation, bleeding

Thoracic No increased risk. One report increased transfusion

Orthopaedic Major joint but not NOF increase bleeding and transfusion

Urology TURP increased risk

Intra abdominal ‘Safe’

Cardiac Increased bleeding Reoperation rate 1.6 to 9.8%,

Transfusion 51% vs 73% and Blood Units 1.6 vs 3.0

Perioperative management of antiplatelet therapy A. D. Oprea* and W. M. Popescu Br. J. Anaesth. (2013) 111 (suppl 1): i3-i17.

Harrington RA, Becker RC, Ezekowitz M et al. Antithrombotic therapy for coronary artery disease: theSeventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 supplement): 513S–548S.Popma JJ, Berger P, Ohman EM et al. AntithromboticYusuf S, Zhao F, Mehta SR, et al, CURE Trial Investigators. Effects of clopidogrel in addition to aspirin inpatients with acute coronary syndromes without ST-segment elevation. The New England Journal of Medicine 2001; 345: 494–502.

Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324:71.

Thrombosis Risk of DAP withdrawal

• Acute withdrawal AP

• Rebound increased platelet adhesiveness

• Prothrombotic due to excessive thromboxane A2

• Decreased fibrinolysis associated with Acute-phase reaction with Surgery.

• DES thrombosis of 1.5% first year, but If discontinue hazard ratio 57 and if instent stenosis - mortality 45%.

• Clopidigrel stop in first month 10x likely to die.Perioperative use of anti-platelet drugs Pierre-Guy Chassot et al. Best Practice & Research Clinical Anaesthesiology. Vol. 21, No. 2, pp. 241–256, 2007

Coronary Stents and non cardiac surgery. Riddell JW et al . Circulation 2007;116 e378-82

Low

High Bleeding Risk

Low Bleeding Risk

Thrombosis RiskSurgery Time Hours

Day

Week

High

High-risk situations:<6 weeks after MI, PCI, stroke<6 weeks after bare metal stent<3 months after stent sirolimus<6 months after stent paclitaxelmultiple stent implantations,long stent (>36 mm), chronictotal occlusions and bifurcation

Intermediate Bleeding Risk

Intracranial neurosurgerySpinal canal surgeryEye Posterior chamber

Visceral SurgeryCardiovascular Major OrthopaedicOtolarygologyUrologicalReconstructive Surgery

PeripheralMinor orthopaedic, otolyngologyEndoscopyEye Anterior chamber

Three Variables: Time Critical Surgery and DAP

18 Scenariosplus

the ‘what-ifs’Perioperative management of antiplatelet therapy A. D. Oprea* and W. M. Popescu Br. J. Anaesth. (2013) 111 (suppl 1): i3-i17.

Cancel

Resolve - 5 D Delay - 1 D

Proceed

Therapy Options

Duration depends on Stent Cancel till on single platelet therapy

1. Withdraw Clopidogrel

2. Withdraw Clopidogrel plus Tirrofiban bridging Early reinstitution DAP Monitoring

1. Withdraw Clopidogrel

2. Platelet Bridging therapy

Low Bleeding Risk

Perioperative use of anti-platelet drugs Pierre-Guy Chassot et al. Best Practice & Research Clinical Anaesthesiology. Vol. 21, No. 2, pp. 241–256, 2007

Perioperative management of antiplatelet therapy A. D. Oprea* and W. M. Popescu Br. J. Anaesth. (2013) 111 (suppl 1): i3-i17.

Coronary Artery Stents and Surgery; the basis of sound perioperative managment. Bolsin S, Hiew C et al. Health 2013, 5 (10) 1730-1736.

No consensus on Bridging DES

American Chest Physicians No bridging

Australia/ NZ Cardiac society G11b/111a inhibitor and heparin

French LMW Heparin plus NSAID

Austrian Anesthesiology Society G11b/111a inhibitor

Japanese Circulation Society Heparin

Perioperative Management of Antiplatelet Therapy in Patients with a Coronary Stent who need a Non Cardiac Surgery: A Systematic Review of Clinical Practice Guidelines. Darvish-Kazem S et al. Chest 2013: 144(6): 1848-1856.

Bridging DES• Site needs 24/7 PCI service

• Monitor in HDU

• Heparins no value

• Tirofiban/ Heparin - 5 days cease Clopidogrel, 3days prior to surgery Tirrofiban and heparin 8hrs prior to surgery

• >100 patients treated with no instent thrombosis -’minor bleeding”

Broad L, Lee T, Conroy M, et al. Successful management of patients with a drug-eluting coronary stent presenting for elective, non-cardiac surgery. Br J Anaesth. 2007;98(1):19-22.Conroy M, Bolsin SN, Black SA, Orford N. Perioperative complications in patients with drug-eluting stents: a three-year audit at Geelong Hospital. Anaesth Intensive Care. 2007;35(6):939-944.Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285-291. [Bolsin SN, Chin H, Birdsey G, Colson M, Gillet J. Coronary artery stents and surgery; the basis of sound perioperative management. Health. 2013;5(10):1730-1736. 

Bridging Therapy for early surgery with DES

36 patients No MACE at 30 days6/36 bleeding requiring transfusion.Cease DAP 5 days prior to surgeryAdmit 2-3 days Tirofiban therapy Stop Tirofiban 4 hrs prior to surgery.Text

Which Stent?BMS BioCompatible

Genous R Stent2nd Gen DES

EverolimusZotarolimus

1st Gen DES

SirolimusCypher

PaclitaxelTaxus

4-6 weeks 12 months 6 months 10 Days

ACS

Clopidogrel Therapy

Surgery

Bridging - Tirofiban and Heparin

Coronary Artery Stents and Surgery; the basis of sound perioperative managment. Bolsin S, Hiew C et al. Health 2013, 5 (10) 1730-1736.

Bridging For Surgery 24 hours

Platelet transfusion for reversal of dual antiplatelet therapy in patients requiring urgent surgery: a pilot studyT. THIELE1,†, A. SÜMNIG1,†, G. HRON1, C. MÜLLER2, K. ALTHAUS1, H. W. S. SCHROEDER2 andA. GREINACHER Journal of Thrombosis and Haemostasis Volume 10, Issue 5, pages 968–971, May 2012

Aspirin Clearance 2hrs, Clopidogrel Clearance 6-8hrs and metabolite 6-8 hours.

Note: Prasugrel and Ticagrelor is 8 and 13 h respectively, with up to 96 h of increased bleeding risk for the latter agent.

Rational:1. Platelet transfusion 5 half lives after cessation of Clopidogrel. 2. ASA affected platelets recruited by thromboxane in Platelet concentrate. 1/14 bleeding, 1/14 Acute Coronary Syndrome ( new territory to stents)

Taylor G, Osinski D, Thevenin A, Devys JM. Is platelet transfusion efficient to restore platelet reactivity in patients who are responders to aspirin and/or clopidogrel before emergency surgery? J Trauma Acute Care Surg 2013;74:1367-9.

Caution - Platelets within the time frame of Clopidogrel working will just reverse aspirin and may increase thrombosis.

Australian Prescriber VOLUME 37 : NUMBER 6 : DECEMBER 2014 182-6.

Text

“If appropriate, prasugrel should be ceased seven days before elective surgery, and ticagrelor between 3 and 5 days, depending on the patient’s thrombotic risk.”

Resolve - Drugs

Resolve - Drugs

Paul A. Gurbel, MD; Kevin P. Bliden et al. Randomized Double-Blind Assessment of the ONSET and OFFSET of the Antiplatelet Effects of Ticagrelor Versus Clopidogrel in Patients With Stable Coronary Artery Disease. The ONSET/OFFSET Study Circulation.2009; 120: 2577-2585

Time to 10% IPA Ticagrelor 109.19 hrs 4.5 Days Clopidogrel 195.66 hrs 8.1 Days

Clopidogrel 600mg/75mgBD, v Ticagrelor180mg/90mg BD

Minor Bleeding-related events Ticagrelor group 28.1%Clopidogrel 13.0% Placebo 8.3%

Reversible Non competitive ADP-P2Y12Non Reversible ADP-P2Y12

Chlopidogrel - Cmax of the active thiol derivative (T1/2 30 mins) is 2.0 x for a four fold increase in the dose. ie 300mg 2.0 x effect of 75mg BD dosing.

Resolve

Oral Anticoagulants

New Oral AnticoagulantsCrCl

ml/minHigh Bleeding

SurgeryLow Bleeding

Surgery Therapy

Apixaban Eliquis 48hrs 24hrs

APCCPCCrFV11

RivaoxabanXarelto

>50<80 48hrs 24hrs APCCPCCrFV11<30 72hrs 48hrs

DabigatranPradaxa

>80 2 days 24hrs DialysisrFV11

prothrombin X

12 hours after last dose.

>50<80 2-3 days 1-2 days

>30<50 4 days 2-3 days

<30 5days

TGA PI Apixaban, Rivaoxaban, Dabigatran

Resolve

Delay

• Figure 1

Clinical course of dabigatran-associated massive postcardiac surgery bleeding.

Theodore E. Warkentin et al. Blood 2012;119:2172-2174

©2012 by American Society of Hematology

79 year, 80kg, AVR + CABGx1

Dabigatran 150mg BDstopped 48hrs before surgery.

CrCl 36mls/hr

[Dabigatran] level of 95ng/ml (same as in the RE-LY study Warfarin vs Dabigatran 110mg or150mg bd)

Recomendationrfv11a

Abdominal Surgery 30%

Cirrhotic Patients and Open Cholecystectomy Mortality 23-50%

Cardiac Surgery 16-31%

Laparotomy for Trauma 45%

Oesophageal Surgery 17-26%

Mortality in patients with Cirrhotic Liver disease:

Anaesthesia considerations: Hyperdynamic cardiovascular system of sepsis

Altered drug kinetics Hypoxia - Hepatopulmonary syndromeAltered neurological stateHyponatraemia and central pontine demyelinationGlucose metabolismCoagulation

Cancel Liver Disease

Cancel

• The Diagnosis

• Wrong operation is planned

• The operation will not benefit the patient.

80 yr old female

For MVRepair, Single graft, ?TVR

Severe SOB

PHx Renal Impairment, Hypertension.

Echo: Severe MR, LVH.

E = 69cm/secMV DecT 232msE/Es’ = 17S = 10cm/secD = 33.7 cm sec

Dx Storage Disease. Amyloidosis

Cancelled - Pump Assist - TVR, Single graft, Cardiac Biopsy

Amyloid

Recovered. Died 6 months later.

Delay

Resolve

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