Bridging
According to Dr. Edwards, bridging is not necessary in the vast majority of patients who are on AC prior to the surgery. “There are rare patients who clot within a day or two of stopping AC, but these patients have hematologists who will offer guidance about bridging with IV heparin,” Dr. Edwards said. “Patients with myeloproliferative neoplasms should have their disease well controlled prior to any elective surgery.”
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January 2020While metabolism, and therefore the half life of direct oral anti-coagulants (DOACs), varies from patient to patient, Dr. Edwards said that she generally holds a DOAC for two days for minor procedures such as a lymph node biopsy, and for four days for major surgeries or surgeries that have very vascular beds, like tonsillectomy. “ENT surgeons must remember that AC is in full effect two hours after a dose of a DOAC,” she said. “There is no lag time, as there is with warfarin. In general, it is safe to restart a DOAC by POD two or three.”
IVC Filters
Dr. Edwards added that there is almost no indication for IVC filters in elective surgery. “If a patient is truly hypercoagulable, they will clot above the filter. The rare exception is the patient who develops a VTE after neurosurgery and there is an absolute contraindication to surgery.” Another exception, she said, would be a patient who had a VTE event and needed urgent surgery before he or she could complete three months of AC. “In these circumstances the filter should be removed as soon as possible,” she said.
Renée Bacher is a freelance medical writer based in Louisiana.
Key Points
- In 2012, The American College of Chest Physicians issued guidelines for VTE in non-orthopedic surgical patients.
- Guidelines for low-risk patients could be adapted to otolaryngology, while patients undergoing high-risk procedures should be considered for more aggressive VTE prophylaxis.
Guidelines Wanted
In a 2016 survey published in Head and Neck, 88% of otolaryngologists said they want guidelines from the AAO-HNS on DVT prophylaxis (Head Neck. 2016;38:E341–E345). Until these are put into place, physicians can manage an individual patient’s surgical risk of DVT by using the Caprini score:
Points are accumulated based on factors that include age (ages 41-60 =1 point; 61-74=2 points; 75 and older = 3 points); recent or planned surgery; visible varicose veins; history of inflammatory bowel disease; swollen legs; body mass index above 25; history of heart attack; congestive heart failure; cancer; pregnancy; serious infection; removable leg brace; and more. Conditions that warrant 5 points include prior stroke; elective hip or knee joint replacement surgery; broken hip, pelvis, or leg; serious trauma, such as multiple broken bones; and a spinal cord injury resulting in paralysis.