Perioperative Anticoagulation

[blocks]

Is there a definitive study showing that LMW Heparin is equally effective a heparin drip in bridging inpatients preoperatively?

I am anesthesia bound, med intern on neurology consultation service...we saw a pt. yeterday who had come in Friday, h/o a-fib and rheumatic heart disease on coumadin INR 2.5, in acute CHF exacerbation, in need of mitral valve replacement. Pt. coumadin stopped, placed in SQ LMW heparin per cardiology, scheduled for surgery Tuesday...LMW heparin last dose given Sunday AM....late Sunday PM pt had what turns out to be a large CVA, left MCA territory.

Per cards, LMW heparin is equivalent to heparin drip in such circumstance, but can't heparin drip be turned off closer to operative go time (6-8 hours IV heparin vs 12 hours LMWH per earlier thread)? Any links to publications supporting LMWH vs. hep. drip?


Just curious.

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[militarymd]

As of a year ago, I am aware of no data validating the use of LMWH as a bridge for coumadin, but that practice is very common....using 1 mg/kg dose of Lovenox without measuring anti-Xa levels.

Obviously not good enough for this guy.

 

[blocks]

Thanks for the reply...I am only familiar with the aftermath of this case, but from what I heard cards is adament about LMWH...Very unfortunate case, the patient is in her early 30's.


Let me know if you come across further info.

 

[militarymd]

Thanks for the reply...I am only familiar with the aftermath of this case, but from what I heard cards is adament about LMWH...Very unfortunate case, the patient is in her early 30's.


Let me know if you come across further info.

I spoke too soon.....read this abstract.

LMWH as bridge for surgery

 

[militarymd]

Not a gold standard study, but data none the less. One year old.

Something came out in 2000 looking at using LMWH as anticoagulation after valve surgery, but that is different from bridging for non-cardiac surgery.

 

[blocks]

Interesting...I searched Up to Date and under the article "Management of anticoagulation before and after elective surgery" patients are stratified as high risk for art. thromboembolism and low risk. Low risk includes patients with non-valvular a-fib, but this patient's h/o rheumatic hrt dz. (mitral valve) I think would place her as high risk. Anyways, high risk should have IV heparin until six hours before the procedure, according to UTD.

There is also a link in UTD to a study in CHEST in 2004 that shows no increase in adverse outcomes with LMWH vs. IV heparin, but it is a n=40 retrospective study. Sounds like the lack of a gold standard study backs up your original post on this...

 

[jetproppilot]

Interesting...I searched Up to Date and under the article "Management of anticoagulation before and after elective surgery" patients are stratified as high risk for art. thromboembolism and low risk. Low risk includes patients with non-valvular a-fib, but this patient's h/o rheumatic hrt dz. (mitral valve) I think would place her as high risk. Anyways, high risk should have IV heparin until six hours before the procedure, according to UTD.

There is also a link in UTD to a study in CHEST in 2004 that shows no increase in adverse outcomes with LMWH vs. IV heparin, but it is a n=40 retrospective study. Sounds like the lack of a gold standard study backs up your original post on this...

So where does that leave Dr. Rooh's flamboyant, arrogant post, implying that he had THE ANSWER and all us "private practice slicks" should know better than to mislead residents with our posts???????????????



Just another academic dude taunting the dudes that REALLY do this for a living, as far as I'm concerned.