Please turn over

(hip fracture surgery=high bleeding risk procedure, =neuraxial anesthesia frequently chosen, epidural typically NOT used)

BC Hip Fracture Redesign Anticoagulation Toolkit

Medication name

Elective Surgery Timing of Last

Dose

Acceptable Lab Value

Reversal Agent Indication for Reversal

Condition to proceed to

O.R.

Consistent ASRA Guidelines for Spinal Anesth.

Course of action /Recommended reversal procedure

ASA Continue N/A Platelet Tfx None None Yes clopidogrel (Plavix) 7 days N/A Platelet Tfx None None No Although not consistent with ASRA recommendation for ELECTIVE surgery consider proceeding to

OR adapting anesthetic technique as required. warfarin

(Coumadin) 6 days (INR 2.5) 7 days (INR 3.0)

INR < 1.5 Vit K, Prothrombin Complex Concentrate (Octaplex, Beriplex)

INR ≥ 1.5 INR< 1.5 Yes -Test INR on arrival, if INR ≥1.5 (1.6-5.0), give 5mg vitK (10mg if INR is >5.0) on arrival to ED, repeat INR q12h. If surgery required and INR still ≥1.5, give Octaplex/Beriplex (Pre-Printed Order

protocol). Then operate within 6-8hrs. '-Patients taking warfarin with a CHADS2 score of ≥ 3, previous stroke, mechanical heart valve, or VTE

within 3 months prior to surgery should be assessed for bridging LMWH if warfarin is being held. INR should be checked just prior to procedure or surgery. Consider placing on LMWH prophylaxis

postoperatively to bridge resumed warfarin.

heparin (sq) BID° prophylaxis

continue PTT <1.5 X normal (if >10000 IU/day or TID

regimen)

None None Yes Anesthesia may adjust last dose of heparin to be given at least 8 hr before or 1 hour after neuraxial instrumentation. Assess cases individually.

heparin (IV) therapeutic

4 hours PTT <1.5 X normal Protamine PTT > ? PTT <1.5 X normal

Yes

prophylactic LMWH

(BID or QDaily)

None within 12 hours

anti Xa* rarely needed, consider if poor renal function

N/A N/A condsider waiting as first

line strategy

Yes

therapeutic LMWH*

(BID or QDaily)

None within 36 hours

anti Xa " N/A N/A None Yes 24 or 36

prophylactic fondaprinux

(2.5mg)

None within 24 hrs anti Xa " condsider waiting as first

line strategy

therapeutic fondaprinux

(≥5mg)

None within 48 hrs anti Xa " condsider waiting as first

line strategy

dabigatran ⱡ

150mg, or 110 BID (Pradaxa)

Last dose at least… 48h (GFR Normal)

96h (GFR30-50)

N/A*

N/A^

N/A**

condsider waiting as first

line strategy

Non avail

rivaroxaban ⱡ 20mg QD (Xarelto)

GFR >30*: 48h N/A* N/A^ N/A** condsider waiting as first

line strategy

Non avail

apixaban ⱡ 5mg BID (Eliquis)

GFR >30*: 48h N/A* N/A^ N/A** condsider waiting as first

line strategy

Non avail

° recommendation not valid for TID dosing. The safety of neuraxial blockade in patients receiving doses greater than 10,000 U of UFH daily or more than twice-daily dosing of UFH has not been established. We suggest that the risk and benefits of thrice-daily UFH be assessed on an individual basis and that techniques to facilitate detection of new/progressive neurodeficits (eg, enhanced neurologic monitoring occur and neuraxial solutions to minimize sensory and motor block) be applied (Grade 2C)

Footnotes:

" anti Xa: some assays available but interpretation not reliable and arbitrary because of lack of evidence with clinical correlation. Note that: anti Xa levels not fondaprinux specific.

^ recombinant VIIa, Concentrated factors can be used but no evidence that these work and consider that these agents have increased thrombotic risk

* APTT and INR can still be tested but not to confirm safety but to identify unsafe satus: i.e. patients with a prolonged APTT and prolonged INR should not have neuraxial anesthesia. This does NOT mean that normal APTT or INR < 1.5 are safe.

** drug should be avoided if GFR < 30

ⱡ None of the NOACs (Novel Oral AntiCoagulants) monographs state recommendations on a time period between last dose and when it is safe to put in a spinal. Rivaroxaban metabolism appears linked to liver function: If Mild Impairment (Child-Pugh A) wait at least 2 days, If Moderate Impairment (Child-Pugh B) wait >4days; If Severe Impairment (Child-Pugh C) wait >1 week. Also consider General Anesthetic

References:

American College of Chest Physician Guidelines 9th ed. Chest 2012;141;e326S-e350S. | Canadian Cardiovascular Society Guidelines. Can J Cardiol 2011;27:S1-S59 and Can J Cardiol 2012;28:125-36. | American Society Regional Anesthesia Guidelines. Reg Anesth Pain Med 2010; 35:64-101. | CPS 2013. Product monographs of dabigatran, rivaroxaban and apixaban. | Management Guidelines for Patients Having ELECTIVE Invasive Procedures in Medical Imaging, VGH, 2013.

THESE GENERAL RECOMMENDATIONS DO NOT REPLACE CLINICAL JUDGEMENT. PHYSICIANS MUST CONSIDER RELATIVE RISKS AND BENEFITS IN EACH PATIENT IN APPLYING THESE RECOMMENDATIONS AND SHOULD REFER TO REFERENCE GUIDELINES FOR MORE DETAILS AND INFORMATION.

Additional note:

Present information is based on current evidence regarding single agents with evidence mainly around elective surgery. The Effect of Combined agents (eg ASA + another agent) remains unknown