Peri-Procedure Management of Anticoagulants Page 1 of 25

Peri-Procedure Management of Anticoagulants

Page 1 of 30

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,

and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to

determine a patient's care. This algorithm should not be used to treat pregnant women.

TABLE OF CONTENTS

Management According to Procedure Type..¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­..¡­¡­..¡­¡­.¡­..¡­¡­¡­. Page 2

APPENDIX A: Procedure Bleeding Risk¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­..Pages 3-8

APPENDIX B: Reversal of Anticoagulants.¡­..¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.........Pages 9-10

APPENDIX C: Management of Anticoagulant for Regional Anesthesia (neuraxial and deep peripheral nerve

procedures, including lumbar puncture).¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­.¡­..¡­¡­¡­¡­¡­...Pages 11-12

APPENDIX D: Procedure Bleeding Risk and Management of Anticoagulants for Interventional Spine and Pain

Procedures...¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­.¡­.........Pages 13-15

APPENDIX E: Procedure Bleeding Risk and Management of Anticoagulants for Neurosurgery Procedures¡­¡­¡­¡­..Pages 16-19

APPENDIX F: Parenteral Anticoagulant Management¡­¡­¡­¡­...¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­Pages 20-22

APPENDIX G: Warfarin Management¡­......¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­. Page 23

APPENDIX H: Direct Oral Anticoagulants (DOACs) Management.¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­... Pages 24-25

APPENDIX I: Thromboembolic Risks..¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.¡­¡­¡­¡­¡­¡­¡­¡­Page 26

APPENDIX J: Child-Pugh Scoring System¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­¡­¡­¡­¡­¡­¡­...¡­¡­¡­¡­¡­¡­¡­¡­¡­. Page 27

Suggested Readings..¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­ Pages 28-29

Development Credits...¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­¡­.Page 30

Copyright 2022 The University of Texas MD Anderson Cancer Center

Department of Clinical Effectiveness V7

Approved by the Executive Committee of the Medical Staff on 10/18/2022

Page 2 of 30

Peri-Procedure Management of Anticoagulants

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,

and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to

determine a patient's care. This algorithm should not be used to treat pregnant women.

PRESENTATION

(Inpatient or Outpatient)

Patient on anticoagulant

scheduled for procedure1

(The primary care team will

determine whether the

procedure can be done safely

while the patient is on an

anticoagulant after discussion

with the patient regarding the

overall risk of bleeding)

EVALUATION

Regional anesthesia

(neuraxial and peripheral

nerve procedures including

lumbar puncture)

or

Interventional spine and

pain procedures

or

Neurosurgery procedures

Other

procedures

Yes

Low

bleeding risk

procedure4?

No

MANAGEMENT PRE- AND POST-PROCEDURE

¡ñ If

urgent or emergent procedure, consider anticoagulant reversal if indicated (see Appendix B)

2,3

¡ñ If possible, delay elective procedures for 1 month after acute VTE or ischemic stroke

¡ñ In patients with new onset atrial fibrillation/atrial flutter who have been on anticoagulation for

< 1 month, recommend TEE to rule out cardiac thrombus prior to holding anticoagulant therapy

¡ñ See Appendix C for management of anticoagulants for regional anesthesia (neuraxial and

peripheral nerve procedures including lumbar puncture)

¡ñ See Appendix D to determine bleeding risk and for management of anticoagulants based on

bleeding risk for interventional spine and pain procedures

¡ñ See Appendix E to determine bleeding risk and for management of anticoagulants based on

bleeding risk for neurosurgery procedures

Continue current

anticoagulant

Urgent/

emergent

procedure?

¡ñ Consider

Yes

1

possible, delay elective

procedures for 1 month after

acute VTE or ischemic stroke2,3

¡ñ In patients with new onset

atrial fibrillation/atrial flutter

who have been on

anticoagulation for < 1 month,

recommend TEE to rule out

cardiac thrombus prior to

holding anticoagulant therapy

For patients on antiplatelet therapy, see Peri-Procedure Management of Antiplatelet Therapy algorithm

For patients with recent ischemic stroke, consult Neurology for further recommendations as indicated

3

Consider removable inferior vena cava (IVC) filter for patients with recent (within 1 month) proximal

lower extremity DVT or PE if procedure cannot be delayed and anticoagulation is expected to be on

hold for > 5 days. Benign Hematology consultation recommended.

4

See Appendix A for Procedural Bleeding Risks based on type of procedure

5

See Appendix I for Thromboembolic Risks

6

If patient is on parenteral anticoagulant, see Appendix F; if on warfarin, see Appendix G; if on DOACs, see Appendix H

2

Copyright 2022 The University of Texas MD Anderson Cancer Center

For restart recommendations, refer

to management based on anticoagulant:

¡ñ Parenteral agents, see Appendix F

¡ñ Warfarin, see Appendix G

¡ñ DOACs, see Appendix H

anticoagulant6

¡ñ Do NOT bridge if patient is on warfarin

¡ñ Do NOT bridge if patient is on DOAC

¡ñ Interrupt

¡ñ If

No

DOACs = direct oral anticoagulants

TEE = transesophageal echocardiogram

VTE = venous thromboembolism

anticoagulant reversal if indicated

(see Appendix B)

¡ñ In patients with new onset atrial fibrillation/atrial flutter

who have been on anticoagulation for < 1 month,

consider TEE to rule out cardiac thrombus prior to

holding anticoagulant therapy

Patient

with low

thromboembolic

risk5?

Yes

anticoagulant6

¡ñ Bridge if patient is on warfarin (see

Appendix G)

¡ñ For moderate risk bleeding procedures,

do NOT bridge if patient on DOAC

¡ñ For high risk bleeding procedures,

bridge if patient on DOAC (see

Appendix H for bridging considerations)

¡ñ Interrupt

No

Department of Clinical Effectiveness V7

Approved by the Executive Committee of the Medical Staff on 10/18/2022

Page 3 of 30

Peri-Procedure Management of Anticoagulants

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,

and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to

determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX A: Procedure Bleeding Risk

Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.

High Bleeding Risk

Moderate Bleeding Risk

Low Bleeding Risk

General Procedures

¡ñ Regional

anesthesia (neuraxial and deep peripheral nerve

procedures) including lumbar puncture (see Appendix C)

Bone marrow aspiration and biopsy

¡ñ Venous port placement

¡ñ

¡ñ

Ommaya reservoir puncture

Breast Surgical and Breast Radiology Procedures

¡ñ All

OR Breast Surgical procedures

¡ñ Vacuum

assisted breast biopsies (MRI/stereotactic)

¡ñ Core

biopsy of breast and/or axillary level 1 nodal basin

needle aspiration of breast, axillary nodal basins, internal

mammary, and/or supraclavicular lymph nodes

¡ñ Image guided pre-operative localization of the breast and

axillary level 1 nodal basin

¡ñ Breast punch biopsy in clinic

¡ñ Fine

Cardiology Procedures

¡ñ Coronary

¡ñ

¡ñ

¡ñ Endomyocardial

intervention

biopsy

¡ñ Implantable cardioverter-defibrillator/pacemaker lead

extraction

¡ñ Left atrial appendage occlusion device

¡ñ Pericardiocentesis

¡ñ

Diagnostic coronary angiography via femoral access

Electrophysiology testing and/or ablation

¡ñ Pacemaker or defibrillator placement

¡ñ Right heart catheterization

¡ñ Supraventricular tachycardia ablation

¡ñ Transvenous atrial fibrillation ablation

¡ñ

Arterioventricular node ablation

Coronary artery angiography (radial approach)

¡ñ Internal cardiac defibrillator implantation battery change

¡ñ Permanent pacemaker implantation battery change

Dental Procedures1

Alevolar surgery (bone removal)

(root removal)

¡ñ Complex dental procedure/multiple tooth extraction

¡ñ Reconstructive dental procedures

Endodontic (root canal) procedures

Peridontal surgery, abscess incision

¡ñ Up to 2 tooth extractions

¡ñ

¡ñ

¡ñ

¡ñ Apicoectomy

¡ñ

¡ñ

Dental hygiene

Minor dental procedures

Dermatologic Procedures

N/A

1

For moderate risk of bleeding dental procedures in patients on vitamin K antagonists (VKA),

either continue VKA in combination with a pro-hemostatic mouthwash or hold VKA 2-3 days prior to procedure

Copyright 2022 The University of Texas MD Anderson Cancer Center

N/A

Dermatologic procedures

¡ñ Mohs Center procedures

¡ñ

Continued on next page

Department of Clinical Effectiveness V7

Approved by the Executive Committee of the Medical Staff on 10/18/2022

Page 4 of 30

Peri-Procedure Management of Anticoagulants

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,

and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to

determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX A: Procedure Bleeding Risk - continued

Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.

High Bleeding Risk

Moderate Bleeding Risk

Low Bleeding Risk

Gastroenterology Procedures

Biliary or pancreatic sphincterotomy and/or dilation

¡ñ Cystogastrostomy

¡ñ Endoscopic hemostasis

¡ñ Endoscopic submucosal dissection (ESD), endoscopic

mucosal resection (EMR) or other polypectomy

¡ñ Endoscopic ultrasound with fine needle aspiration

¡ñ Full thickness resection

¡ñ Percutaneous endoscopic gastrostomy (PEG) placement

¡ñ Pneumatic or bougie dilation

¡ñ Therapeutic balloon-assisted enteroscopy

¡ñ Treatment of varices

¡ñ Tumor ablation by any technique

¡ñ

Barrett¡¯s esophagus ablation

¡ñ Colonoscopy with biopsy

¡ñ Diagnostic balloon-assisted enteroscopy

¡ñ Endoscopic retrograde cholangiopancreatography (ERCP)

with stent and/or biopsy

¡ñ Esophageal or enteral stent

¡ñ Gastroscopy with biopsy

¡ñ Sigmoidoscopy with biopsy

¡ñ

Capsule endoscopy

¡ñ Colonoscopy without biopsy

¡ñ Diagnostic esophagogastroduodenoscopy (EGD)

¡ñ Endoscopic retrograde cholangiopancreatography (ERCP)

diagnostic

¡ñ Endoscopic ultrasound without fine needle aspiration

¡ñ Push enteroscopy without biopsy

¡ñ Sigmoidoscopy without biopsy

¡ñ

Gynecology Oncology Procedures

¡ñ

All other Gynecology Oncology procedures

Cold knife conization (CKC)/loop electrosurgical excision

procedure (LEEP)

¡ñ Superficial wide local excisions

¡ñ

Colposcopy

¡ñ Dilatation and curettage

¡ñ Endometrial biopsy

¡ñ Exam under anesthesia

¡ñ Hysteroscopy

¡ñ Insertion/Removal of intrauterine device

¡ñ Laser ablation of the cervix/vulva/vagina

¡ñ Vulvar/vaginal/cervical biopsies

¡ñ

Head and Neck Surgery Procedures

¡ñ All

other Head and Neck Surgery procedures

N/A

¡ñ

Flexible nasopharyngeal laryngoscopy (when performed

outside of the OR)

Continued on next page

Copyright 2022 The University of Texas MD Anderson Cancer Center

Department of Clinical Effectiveness V7

Approved by the Executive Committee of the Medical Staff on 10/18/2022

Page 5 of 30

Peri-Procedure Management of Anticoagulants

Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,

and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to

determine a patient's care. This algorithm should not be used to treat pregnant women.

APPENDIX A: Procedure Bleeding Risk - continued

Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.

High Bleeding Risk

Moderate Bleeding Risk

Low Bleeding Risk

Interventional Radiology Procedures

Ablations: solid organs, bone, soft tissues, lung

¡ñ Angiography with arterial intervention (e.g., angioplasty) with

access size > 6 French

¡ñ Aortic stent graft

¡ñ Catheter directed thrombolysis (arterial and venous)

¡ñ Gastrostomy, jejunostomy tube placement

¡ñ Intrathecal chemotherapy

¡ñ Lung interventions: biopsy, fiducial placement, intratumoral

injection, and drainage (parenchymal)

¡ñ Percutaneous embolectomy, thrombectomy

¡ñ Portal vein embolization and stenting

¡ñ Solid organ biopsies, fiducial placement, and intratumoral

injection (e.g., liver, prostate, cervical)

¡ñ Solid organ drainage: nephrostomy, biliary, cholecystostomy

¡ñ Spine procedures: vertebroplasty, kyphoplasty (see Appendix D)

¡ñ Transjugular intrahepatic porto-systemic shunt (TIPS)

¡ñ Venous interventions (intrathoracic, intracranial)

¡ñ

Carotid stent placement

¡ñ Catheter exchange < 6 weeks from initial placement (e.g.,

biliary, nephrostomy, abscess, gastrostomy, jejunostomy)

¡ñ Deep, non-organ biopsy, fiducial placement, and

intratumoral injection

¡ñ Diagnostic angiography, with access size up to 6 French

¡ñ Non-organ drainage (e.g., abdominal or retroperitoneal

abscess)

¡ñ Non-tunneled chest tube placement (pleural space)

¡ñ Thoracentesis

¡ñ Trans-arterial embolotherapy

¡ñ Transjugular liver biopsy

¡ñ Tunneled central venous catheter placement

¡ñ Tunneled drainage catheter placement or removal

¡ñ Venous interventions (peripheral)

¡ñ Venous port placement

¡ñ

Catheter exchange > 6 weeks from initial placement (e.g.,

biliary, nephrostomy, abscess, gastrostomy, jejunostomy)

¡ñ Diagnostic angiography (radial approach)

¡ñ Intraperitoneal catheter placement

¡ñ Inferior vena cava filter placement or retrieval

¡ñ Non-tunneled central line placment or removal

¡ñ Paracentesis

¡ñ Superficial (e.g., lymph nodes, thyroid) or palpable mass

biopsies, fiducial placement, and intratumoral injection

¡ñ Superficial abscess drainage

¡ñ Tunneled central venous catheter removal

¡ñ Venous port removal

¡ñ

Neuro-Oncology Procedures

¡ñ

¡ñ

Paraspinal, Diaphragm Electromyography (EMG)

Lumbar puncture (see Appendix C)

¡ñ

Deep muscle (gastrocnemius, infraspinatus, supraspinatus)

EMG

¡ñ

Superficial muscle EMG

¡ñ

Superficial or palpable mass biopsies

Neuroradiology Procedures

¡ñ

¡ñ

Lumbar puncture (see Appendix C)

Solid organ biopsies

¡ñ

Deep, non-organ biopsy

Continued on next page

Copyright 2022 The University of Texas MD Anderson Cancer Center

Department of Clinical Effectiveness V7

Approved by the Executive Committee of the Medical Staff on 10/18/2022

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download