Patient Care Hematology & Oncology - October 2007 - (Page 12)

I Bridge anticoagulation UFH protocol A past history of HIT must first be ruled out. Warfarin is discontinued 4 to 5 days prior to the elective procedure. The patient is hospitalized 2 days preoperatively to begin a continuous infusion of UFH. The aPTT is monitored every 6 hours to ensure that it is in the therapeutic range. UFH is discontinued 4 to 6 hours before the procedure. Immediately preprocedure, the aPTT is checked to confirm reversal of the anticoagulated state. If the aPTT remains too high, protamine is given to reverse it. Approximately 12 hours postprocedure, a continuous UFH infusion is resumed, while the aPTT is followed serially to ensure therapeutic levels. Warfarin is administered concurrently or as soon as the patient is able to take oral medication. UFH is continued for at least 5 days but discontinued when the INR reaches the target range.9 LMWH protocol Before this protocol can be safely administered, it must be established that the patient has never had HIT, that renal function is preserved, and that the patient is educable, compliant with instructions, and capable of SC self-injection. Aspirin and/or antiplatelet drugs are discontinued 8 days before the procedure. Warfarin is stopped 4 to 6 days before the procedure. Subcutaneous LMWH injections begin 2 to 4 days before the procedure. The last LMWH injection occurs 12 or 24 hours preprocedure. Twelve hours postprocedure, or when postoperative hemostasis is established, LMWH injections resume, and the patient resumes warfarin concurrently or as soon as he or she is able to take oral medication. LMWH is discontinued when the INR is therapeutic.10 Hospital confinement is limited to the day of the procedure and for postoperative needs, not for any anticoagulation needs. TABLE 3 Proposed bridge protocol using UFH Days preceding Day of surgery Days after Tasks 8 Assess need for bridging Assess risk Stop aspirin Discontinue warfarin Hospitalize patient Start UFH to increase aPT 0 Discontinue UFH Surgery 0.5-1 1 2-4 Start UFH to increase aPTT Start warfarin Titrate warfarin to target INR Discontinue UFH 2.5 4-6 2 2.5 Key: aPTT, activated partial thromboplastin time; INR, international normalized ratio; UFH, unfractionated heparin. Issues unique to LMWH bridge therapy Since there are no randomized controlled trials to assure the safety and efficacy of LMWH in periprocedural bridging, a careful risk-benefit analysis should be undertaken prior to its use. Once LMWH bridging is employed, the care providers should be particularly attentive for signs and symptoms of thrombotic complications. Bridging with LMWH is not appropriate in patients with a history of HIT. It is also ill advised to use LMWH in patients undergoing neuraxial anesthesia or spinal puncture, since these patients are at risk for development of epidural and/or spinal hematoma that may result in paralysis. 12 PATIENT CARE HEMATOLOGY & ONCOLOGY www.patientcareonline.com http://www.patientcareonline.com

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Patient Care Hematology & Oncology - October 2007

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