Full Dose Lovenox 12 hrs prior to CABG

[MDF1]

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Cancelled a case recently for this. Surgeon still giving me flak about it although we do have a good relationship. Pt was fresh out of the cath lab. Nstemi a week ago, stable vitals, and cp free, No LM disease. He had been on 100mg bid lovenox for 3 or 4 days. Surgeon wanted to go and said well just give ffp if he bleeds. What do you guys think?

 

[dhb]

Operation?

 

[MDF1]

Operation?

Cabg

 

[deleted87051]

Good question. Some conflicting data.




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Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronary artery bypass surgery.
Authors
Medalion B, et al. Show all
Journal
J Thorac Cardiovasc Surg. 2003 Dec;126(6):1875-9.

Affiliation
Comment in

• J Thorac Cardiovasc Surg. 2004 Aug;128(2):327-8.

Abstract
BACKGROUND: The purpose of this study was to determine whether the use of low-molecular-weight heparin before coronary artery bypass surgery would be associated with an increase in bleeding and use of blood products after the operation.

METHODS: Sixty-four patients (48 men and 16 women) aged 64 +/- 10 years who were undergoing primary coronary artery bypass surgery were prospectively studied. Forty-one patients were treated with either subcutaneous enoxaparin 1 mg/kg twice daily (n = 21; enoxaparin group) or intravenous heparin (n = 20; heparin group). Patients received the last dose of enoxaparin 8.7 +/- 0.75 hours (range, 8-10 hours) before skin incision. Heparin was stopped before transfer to the operating room. An additional 23 consecutive patients who received neither enoxaparin nor heparin served as controls (n = 23). Anti-factor Xa activity, a measure of enoxaparin and heparin activity, was measured at the start of the operation in all patients.

RESULTS: There was no perioperative mortality. The length of stay and frequency of postoperative complications were similar between groups. Preoperative anti-factor Xa activity was present only in the enoxaparin group (0.43 +/- 0.25 IU/mL). Chest tube drainage at 24 hours was 553 +/- 160 mL, 532 +/- 140 mL, and 587 +/- 230 mL for the enoxaparin, heparin, and control groups, respectively (P =.48). There was no difference among groups in the amount of blood products transfused.

CONCLUSIONS: Enoxaparin administration more than 8 hours before coronary artery bypass surgery is not associated with increased postoperative bleeding or blood product transfusion.

PMID
14688699 [PubMed - indexed for MEDLINE]
Full text: Elsevier Science
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• Effects of preoperative enoxaparin versus unfractionated heparin on bleeding indices in patients undergoing coronary artery bypass grafting.
• Surgical bleeding after pre-operative unfractionated heparin and low molecular weight heparin for coronary bypass surgery.
• Fondaparinux or enoxaparin: a comparative study of postoperative bleeding in coronary artery bypass grafting surgery.
• Heparin resistance and increased platelet activation in coronary surgery patients treated with enoxaparin preoperatively.
• Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports.

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[deleted87051]

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Effects of preoperative enoxaparin versus unfractionated heparin on bleeding indices in patients undergoing coronary artery bypass grafting.
Authors
Kincaid EH, et al. Show all
Journal
Ann Thorac Surg. 2003 Jul;76(1):124-8; discussion 128.

Affiliation
Abstract
BACKGROUND: We examined the effects of preoperative administration of enoxaparin (ENOX), a low-molecular-weight heparin, on bleeding indices and transfusion rates in patients undergoing coronary artery bypass grafting (CABG).

METHODS: Patients undergoing isolated CABG between 1997 and 2002 who received preoperative ENOX or a continuous infusion of unfractionated heparin (UFH) were randomly divided into three groups: continuous UFH, ENOX last administered more than 12 hours before surgery (ENOX > 12), and ENOX administered less than 12 hours before surgery (ENOX < 12). Perioperative hemoglobin values, transfusion rates, and bleeding complications were compared.

RESULTS: A total of 69, 58, and 34 patients comprised the UFH, ENOX > 12, and ENOX < 12 groups, respectively. Preoperative demographics and hematologic data were similar among the groups. Compared with the UFH group, the ENOX < 12 group had significantly lower postoperative hemoglobin values (9.6 +/- 1.3 g/dL versus 10.4 +/- 1.2 g/dL, p < 0.05), higher transfusion rates (73.5% versus 50.7%, p < 0.05), and required more total packed red cells per patient (882 +/- 809 mL versus 472 +/- 626 mL, p < 0.05). A nonsignificant increase was noted in the risk of returning to the operating room for bleeding in patients who had received ENOX compared with patients receiving UFH (6.5% versus 2.9%).

CONCLUSIONS: The preoperative use of ENOX less than 12 hours before CABG is associated with lower postoperative hemoglobin values and higher rates of transfusion than continuous UFH.

PMID
12842525 [PubMed - indexed for MEDLINE]
Full text: Elsevier Science
Related Citations
Show all

• Surgical bleeding after pre-operative unfractionated heparin and low molecular weight heparin for coronary bypass surgery.
• Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronary artery bypass surgery.
• Early postoperative use of unfractionated heparin or enoxaparin is associated with increased surgical re-exploration for bleeding.
• Preoperative use of enoxaparin compared with unfractionated heparin increases the incidence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome: clinical investigation and reports.
• Safety and efficacy of switching from either unfractionated heparin or enoxaparin to bivalirudin in patients with non-ST-segment elevation acute coronary syndromes managed with an invasive strategy: results from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial.

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[deleted87051]

IMO a lot depends on your surgeon. I would not have cancelled. The differences don't seem clinically relevant.

 

[dhb]

Cabg

is he not getting 25.000 units of heparine anyway?

 

[MDF1]

Of course he is. And that heparin will be reversed with protamine, lovenox, not so much, and not even necessarily with ffp. I felt that for a case that had no urgency to it. Why not wait the 24 hrs until it is out of his system. Whats the rush if waiting saves him from a transfusion, and possibly a bring back. I did not have the above study to rely on, just a general concensus that elective surgery shldnt be perfromed within 24 hours of a full dose of lovenox. Maybe im splitting hairs but i just wanted to see how others would handle this issue since i didnt get much guidance from any colleagues in my group. They just nodded and said let us know if you cancel it. In fact, our cardiac crna said "well yeah, we do that case, you see because if we dont, the cardiologist will stop referring surgical patients to this particular surgeon" If there was any urgency to it at all I would have done it. I did the case next day and we did not need to transfuse or bring back. I also felt the "lets just do the case and give ffp if he bleeds" was not good patient care, and not in his best interest. Would like more opinions if there are any.

 

[dhb]

No right or wrong here, probably a tiny bit safer regarding post-op bleeding (although this depends mostly on the surgeon) the way you did it

 

[BuzzPhreed]

Would like more opinions if there are any.

LMWH seems to have more Xa activity which you can't reverse as you point out. However you can still get up to 60% reversal with protamine. The guy might have bled in the ICU and they might have blamed you or had to give more product than necessary. Can't say I blame you for waiting in this instance.

We had a not-too-dissimilar issue not that long ago with a patient on Xa inhibitor (I think it was dabigatran) who had to go emergently to the OR for non-cardiac. Nothing you could do. Just grip it and rip it. Bled like stink.

 

[OB1🤙]

At least you asked the cardiac crna for their expert opinion.

 

[BuzzPhreed]

Also FFP is rich in antithrombin and will actually potentiate the action of heparin, not reverse it. Just FYI. Not a good choice in a heparinized patient if that was your intent.

 

[sluggs]

Not an anesthesiologist, so no final opinion on canceling the case, but I can tell you this: the FFP won't help you if the patient does bleed from LOVENOX. Also, renal function is an important factor to address for lovenox clearance. Did the patient have a normal GFR?

 

[MDF1]

At least you asked the cardiac crna for their expert opinion.

Well you can see what i did with it....

Not an anesthesiologist, so no final opinion on canceling the case, but I can tell you this: the FFP won't help you if the patient does bleed from LOVENOX. Also, renal function is an important factor to address for lovenox clearance. Did the patient have a normal GFR?

Yes normal GFR and i realize ffp wont help you much in lovenox or heparin, the surgeon wanted to do the case and give ffp in case of bleeding, not me.

Thanks for the comments!!

 

[periopdoc]

I would have done exactly what you did in this situation. No urgency, no case. Nothing to gain by pushing the boundaries and the medico-legal risk of proceeding is too high if he ends up with post-op bleeding, whether or not it is related to his Lovenox history.

- pod

 

[OB1🤙]

Agreed.

Also, there should be no such fcucking thing as a cardiac crna.

 

[seinfeld]

Would have waited on doing the case.