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Evaluation of a Standardized Perioperative Management Protocol in the Adult Hematology Anticoagulation Management
Diane J Lum1,2, Patricia A Ross1, Martin A Bishop1
11 The Johns Hopkins Hospital, Baltimore, MD, USA.
Insights
A standardized guideline for perioperative anticoagulation management, informing but not dictating practice, resulted in low rates of thromboembolism and bleeding events. This approach supports safe surgical procedures for patients on anticoagulation.
Area of Science:
- Cardiology
- Hematology
- Surgical Management
Background:
- Annually, 250,000 patients on vitamin K antagonists in North America require surgery.
- Current guidelines recommend temporary anticoagulation interruption and bridging therapy for select patients.
Purpose of the Study:
- To assess adherence to Johns Hopkins clinic guidelines for perioperative anticoagulation management.
- To identify bleeding and thromboembolic events during perioperative anticoagulation management.
Main Methods:
- Retrospective study of 294 patients undergoing invasive procedures from May 2009 to March 2014.
- Prospective development of individualized anticoagulation management plans based on standardized guidelines.
- Data collection on guideline adherence, thromboembolic events, and bleeding complications.
Main Results:
- Low incidence of adverse events: 1 thromboembolism (0.3%), 3 major bleeds (1%), and 21 minor bleeds (7%).
- No significant difference in thromboembolic or bleeding events between adherent and nonadherent providers.
- One adverse event (facial swelling) reported after enoxaparin administration.
Conclusions:
- Standardized guidelines for perioperative anticoagulation management can inform clinical practice effectively.
- This approach leads to low rates of both thromboembolism and bleeding complications.
- Clinical practice informed by guidelines, rather than strictly dictated, ensures patient safety.
Background:
In North America, 250,000 patients on vitamin K antagonists require surgical procedures each year. Temporary interruption of oral anticoagulation and perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin are recommended by the American College of Chest Physicians 2012 for select patients.
Objectives:
The study objectives are to evaluate adherence and nonadherence to the Johns Hopkins clinic guidelines for perioperative management of anticoagulation and identify bleeding or thromboembolic events during perioperative management of anticoagulation.
Methods:
This is a retrospective study of patients who required perioperative management of anticoagulation for an invasive procedure from May 2009 to March 2014. Individualized perioperative anticoagulation management plans were prospectively developed for each patient according to the standardized Johns Hopkins perioperative bridging recommendations and documented in the medical record. Adherence to these standardized Johns Hopkins clinic guidelines, the incidence of thromboembolic events, and bleeding and adverse events during perioperative management were retrieved from the medical record.
Results:
In 294 perioperative management cases, there was 1 (0.3%) thromboembolism, 3 (1%) major bleeds, and 21 (7%) minor bleeds. One patient experienced facial swelling after starting enoxaparin. There was no difference in thromboembolic (0 vs 1, P = 1.00), major (1 vs 2, P = 1.00), or minor bleeding (14 vs 7, P = 1.00) events in patients managed by providers who were adherent to guidelines when compared with providers who were nonadherent.
Conclusion:
Our study shows that using a standardized guideline for perioperative management of anticoagulation to inform but not to dictate clinical practice leads to low rates of both thromboembolism and bleeding.
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