View source for Bleeding perioperative discontinuation, bridging, and reversal of anticoagulation and antiplatelet therapy

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{{Bleeding}}
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==Overview==
The management of perioperative bleeding in the context of anticoagulation and antiplatelet therapy depends on the medication administered to the patient.

==2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)<ref name="Kozek-Langenecker-2013">{{Cite journal  | last1 = Kozek-Langenecker | first1 = SA. | last2 = Afshari | first2 = A. | last3 = Albaladejo | first3 = P. | last4 = Santullano | first4 = CA. | last5 = De Robertis | first5 = E. | last6 = Filipescu | first6 = DC. | last7 = Fries | first7 = D. | last8 = Görlinger | first8 = K. | last9 = Haas | first9 = T. | title = Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. | journal = Eur J Anaesthesiol | volume = 30 | issue = 6 | pages = 270-382 | month = Jun | year = 2013 | doi = 10.1097/EJA.0b013e32835f4d5b | PMID = 23656742 }}</ref>==

====Antiplatelet Agents====

{|class="wikitable" style="width: 80%;"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that [[aspirin]] therapy should continue perioperatively in most surgical settings, especially [[cardiac surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Where [[aspirin]] withdrawal is considered, we recommend a time interval of 5 days. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Clopidogrel]] increases perioperative [[bleeding]]. In cases of increased [[bleeding]] risk, we recommend that it should be withdrawn for no more than 5 days. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Prasugrel]] increases perioperative [[bleeding]]. In cases of increased [[bleeding]] risk, we recommend that it should be withdrawn for no more than 7 days. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' We recommend that [[antiplatelet|antiplatelet agent therapy]] should resume as soon as possible postoperatively to prevent [[platelet activation]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' We recommend postponement of elective [[surgery]] following [[coronary]] [[stenting]] (at least 6 to 12 weeks for [[bare metal stent]] and one year for [[drug-eluting stent]]s). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' We recommend that a multidisciplinary team meeting should decide on the perioperative use of [[antiplatelet|antiplatelet agents]] in urgent and semi-urgent [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For intra- or postoperative [[bleeding]] clearly related to [[aspirin]], we suggest that [[platelet]] [[transfusion]] be considered (dose: 0.7 × 10<sup>11</sup> [i.e. two standard concentrates] per 7 kg body weight in adults). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that the first postoperative dose of [[clopidogrel]] or [[prasugrel]] should be given no later than 24 h after [[skin]] closure. We also suggest that this first dose should not be a [[loading dose]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest that urgent or semi-urgent [[surgery]] should be performed under [[aspirin]]/[[clopidogrel]] or [[aspirin]]/[[prasugrel]] combination therapy if possible, or at least under [[aspirin]] alone. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest that [[platelet]] [[transfusion]] should be considered (dose: 0.7 × 10<sup>11</sup> [i.e. two standard concentrates] per 7 kg body weight in adults) in cases of intra- or postoperative [[bleeding]] clearly related to [[clopidogrel]] or [[prasugrel]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' According to pharmacological characteristics, we suggest that the management of [[ticagrelor]] may be comparable to [[clopidogrel]] (i.e. withdrawal interval of 5 days). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' [[Platelet]] [[transfusion]] may be ineffective for treating [[bleeding]] clearly related to [[ticagrelor]] when given 12 h before. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Heparin====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that severe [[bleeding]] associated with [[intravenous]] [[UFH|unfractionated heparin (UFH)]] should be treated with [[intravenous]] [[protamine]] at a dose of 1 mg per 100 IU [[UFH]] given in the preceding 2–3 h. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that severe [[bleeding]] associated with subcutaneous [[UFH]] unresponsive to [[intravenous]] [[protamine]] at a dose of 1 mg per 100 IU [[UFH]] could be treated by continuous administration of [[intravenous]] [[protamine]], with dose guided by [[aPTT]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that severe [[bleeding]] related to subcutaneous [[LMWH|low molecular weight heparin (LMWH)]] should be treated with [[intravenous]] [[protamine]] at a dose of 1 mg per 100 anti-[[Factor X|Xa]] units of [[LMWH]] administered. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest that severe [[bleeding]] associated with subcutaneous [[LMWH]] and unresponsive to initial administration of [[protamine]] could be treated with a second dose of [[protamine]] (0.5 mg per 100 anti-[[Factor X|FXa]] units of [[LMWH]] administered). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Fondaparinux====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that the administration of [[Factor VII|rFVIIa]] could be considered to treat severe [[bleeding]] associated with subcutaneous administration of [[fondaparinux]] (off-label treatment). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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|}

====Vitamin K Antagonists====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that [[VKA|vitamin K antagonists (VKAs)]] should not be interrupted for skin [[surgery]], dental and other oral procedures, gastric and colonic [[endoscope|endoscopies]] (even if [[biopsy]] is scheduled, but not [[polypectomy]]), nor for most ophthalmic [[surgery]] (mainly anterior chamber, e.g. [[cataract]]), although vitreoretinal [[surgery]] is sometimes performed in [[VKA]] treated patients. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that for low-risk patients (e.g. [[atrial fibrillation]] patients with [[CHADS2 score]] ≤2, patients treated for > 3 months for a non-recurrent [[VTE]]) undergoing procedures requiring [[INR]] <1.5, [[VKA]] should be stopped 5 days before [[surgery]]. No bridging therapy is needed. Measure [[INR]] on the day before [[surgery]] and give 5 mg oral [[vitamin K]] if [[INR]] exceeds 1.5. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend bridging therapy for high-risk patients (e.g. [[atrial fibrillation]] patients with a [[CHADS2 score]] > 2, patients with recurrent [[VTE]] treated for <3 months, patients with a [[mechanical valve]]). Day 5: last [[VKA]] dose; Day 4: no [[heparin]]; Days 3 and 2: therapeutic subcutaneous [[LMWH]] twice daily or subcutaneous [[UFH]] twice or thrice daily; Day 1: hospitalisation and [[INR]] measurement; Day 0: [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' We recommend that for groups 1 and 2 above, [[VKA]]s should be restarted during the evening after the procedure. Subcutaneous [[LMWH]] should be given postoperatively until the target [[INR]] is observed in two measurements. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' We recommend that for group 3 above, [[heparin]] ([[UFH]] or [[LMWH]]) should be resumed 6–48 h after the procedure. [[VKA]] can restart when surgical [[hemostasis]] is achieved. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' We recommend that, in [[VKA]] treated patients undergoing an emergency procedure or developing a [[bleeding]] complication, [[Prothrombin complex concentrate|[[PCC]]]] (25 IU [[Factor IX|FIX]]/kg) should be given. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' We recommend to assess [[creatinine clearance]] in patients receiving NOAs and being scheduled for [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

====New Oral Anticoagulants====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that for low-risk patients (e.g. [[atrial fibrillation]] patients with [[CHADS2 score]] 2, patients treated for >3 months for a non-recurrent [[VTE]]) undergoing procedures requiring normal [[coagulation]] (normal diluted [[thrombin time]] or normal specific anti-[[Factor X|FXa]] level), NOAs can be stopped 5 days before [[surgery]]. No bridging is needed. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that new oral [[anticoagulant]] agents (NOAs) should not be interrupted for skin [[surgery]], dental and other oral procedures, gastric and colonic [[endoscope|endoscopies]] (even if [[biopsy]] is scheduled, but not polypectomy), nor for most ophthalmic [[surgery]], (mainly anterior chamber, e.g. [[cataract]]), although vitreoretinal [[surgery]] is sometimes performed in NOA treated patients. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients treated with [[rivaroxaban]], [[apixaban]], [[edoxaban]] and in patients treated with [[dabigatran]] in which [[creatinine clearance]] is higher than 50 ml/min, we suggest bridging therapy for high-risk patients (e.g. [[atrial fibrillation]] patients with a [[CHADS2 score]] >2, patients with recurrent [[VTE]] treated for <3 months). Day 5: last NOA dose; Day 4: no [[heparin]]; Day 3: therapeutic dose of [[LMWH]] or [[UFH]]; Day 2: subcutaneous [[LMWH]] or [[UFH]]; Day 1: last injection of subcutaneous [[LMWH]] (in the morning, i.e. 24 h before the procedure) or subcutaneous [[UFH]] twice daily (i.e. last dose 12 h before the procedure), hospitalisation and measurement of diluted [[thrombin time]] or specific anti-[[Factor X|FXa]]; Day 0: [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients treated with [[dabigatran]] with a [[creatinine clearance]] between 30 and 50 ml/min, we suggest to stop NOAs 5 days before [[surgery]] with no bridging. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest that for groups 2 and 3, [[heparin]] ([[UFH]] or [[LMWH]]) should be restarted 6–72 h after the procedure, taking the [[bleeding]] risk into account. NOAs may be resumed when surgical [[bleeding]] risk is under control. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Comorbidities Involving Hemostatic Derangement====

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We do not recommend discontinuation of [[Gingko biloba]] extracts. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}

{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that patients with hemostatic derangements associated with systemic, metabolic and endocrine diseases should be managed perioperatively in collaboration with a [[hematologist]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that [[SSRI|selective serotonin reuptake inhibitor (SSRI)]] treatment should not be routinely discontinued perioperatively. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest individualized perioperative discontinuation of [[antiepileptic]] agents, such as [[valproic acid]], which may increase [[bleeding]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

==Sources==

* 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding<ref name="Kozek-Langenecker-2013">{{Cite journal  | last1 = Kozek-Langenecker | first1 = SA. | last2 = Afshari | first2 = A. | last3 = Albaladejo | first3 = P. | last4 = Santullano | first4 = CA. | last5 = De Robertis | first5 = E. | last6 = Filipescu | first6 = DC. | last7 = Fries | first7 = D. | last8 = Görlinger | first8 = K. | last9 = Haas | first9 = T. | title = Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. | journal = Eur J Anaesthesiol | volume = 30 | issue = 6 | pages = 270-382 | month = Jun | year = 2013 | doi = 10.1097/EJA.0b013e32835f4d5b | PMID = 23656742 }}</ref>

==References==

{{reflist|2}}