# 010 Anticoagulation in the Geriatric Surgical Patient
Authors: John Petronovich, Kathryn Denson MD, Bambi Wessel
Objectives:
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List 3 considerations in perioperative anticoagulation management of geriatrics patients.
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Give examples of low, moderate, and high risk thromboembolic states/conditions.
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Explain general anticoagulation perioperative management for each level of risk.
ACGME Competencies: Patient Care, Medical Knowledge
Context: Geriatric patient in a perioperative hospital setting.
Action: Patient undergoing invasive procedure currently taking warfarin for history of thromboembolism.
Incidence/Prevalence: Warfarin use in patients over age 65 reached 12.8% in 2006. Among all patients hospitalized, 9.3% of warfarin users died compared with 4.8% of those not on warfarin1. Among trauma patients, those on warfarin preinjury were 3.1 times more likely to die.2
Assessment:
Considerations
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Patient’s bleeding risk: bleeding history is most important factor. Includes history of excessive bleeding (menorrhagia, hematuria, epistaxis, purpura or petechiae, etc.), coagulopathies, family history of coagulopathies, anticoagulation meds, and coagulation labs such as PT/INR3.
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Patient’s risk of thromboembolism: Most important factor is personal history of venous thromboembolism or DVT/PE. Also consider conditions such as atrial fibrillation, coronary artery disease, diabetes mellitus, hypertension, peripheral vascular disease, heart failure, valvular disease, or the presence of mechanical valves. Also hypercoaguable states such as Factor V Leiden, protein C&S deficiency, etc.3
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Risk of operative procedure: Consider location of surgery, extent of surgery, and ability to control potential bleeds through compression, etc3.
Management of patients with oral anticoagulation4,5
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Annual Risk of Thromboembolism
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Management
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Low (<4%) such as atrial fibrillation with no history of stroke
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Withhold anticoagulation for 4 days prior to surgery, resume full dose postoperatively
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Moderate (4-7%) such as mechanical aortic valve
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Withhold anticoagulation for 4 days prior to surgery, optional to use IV heparin or subcutaneous LMWH when INR subtherapeutic. Resume warfarin post-operatively.
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High (>7%) such as atrial fibrillation with history of stroke
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Withhold anticoagulation for 4 days prior to surgery, use IV heparin or subcutaneous LMWH when INR subtherapeutic, but discontinue prior to surgery. Resume warfarin post-operatively
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Underlying Science: Warfarin is used in patients at risk of thromboembolic conditions. Warfarin is useful in these patients because it decreases the liver’s production of factors II, VII, IX, and X by inhibiting the enzyme vitamin K epoxide reductase complex 1 (VKOR). Doing so prevents the activation of vitamin K to its reduced form, thereby preventing carboxylation of coagulation factors. 24 hours after administration of warfarin, the coagulant activity of blood is decreased to about 20%. Normal coagulation returns 1-3 days after discontinuation of warfarin6.
References:
1. Dossett LA, et al. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Archives of Surgery. 146(5):565-70, May 2011.
2. Bonville DJ, et al. Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients. Surgery. 150(4):861-8, Oct 2011
3. Heit JA, et al. Perioperative management of the chronically anticoagulated patient. Journal of Thrombolysis. 12:81-7. 2001.
4. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Internal Med. 163(8):901-8. Apr 2003.
5. Jafri S. Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy. Am Heart Journal. 147(1): 1-15. 2004.
6. Guyton AC, Hall JE. Textbook of Medical Physiology. St. Louis, MO: Saunders. 11th Edition. 2005.
Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only. Citation: John Petronovich, Kathryn Denson MD, Bambi Wessel - Fast Fact #10: Anticoagulation in the Geriatric Surgical Patient. February 2012, 10, Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm
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