Clexane Bridging in the Anaesthetic Preassessment Clinic

1. Clexane Bridging in the Anaesthetic Preassessment Clinic Dr Paul Sice, Consultant Anaesthetist Derriford Hospital, Plymouth

2. Objectives The problems with the old system The development of the new guideline The clexane bridging pathway The practicalities of making it work Examples

3. The Old System Evidence-based Douketis JD, Johnson JA, Turpie AG. Low-molecular weight Heparin as bridging anticoagulation during interruption of Warfarin. Arch Int Med. 2004; 164: 1319 – 26.

4. The Old System Risk assessment

5. The Old System Clear Instructions

6. The Old System - Difficulties More disparate surgical pre-assessment Day of surgery admission Clinicians doing their own thing Some impractical parts of the protocol

7. The Old System - Difficulties Giving people a choice

8. The Old System - Difficulties Blood testing difficult

9. The Old System - Difficulties Potential for mistakes and variation

10. Geography (patient journeys)

11. General Pre-assessment Clinic Waiting List ENT ? Day of Surgery etc GP / Primary Care Hospital Only New Developments Surgical specialties Pre-assessment Orthopaedics

12. The Workload Review of Clinic Records – 10 weeks 353 60 CPX 46 ECG check 247 Warfarin Decisions 44 20%

13. A New Guideline Evidence Based Minimise Patient Journeys Patient Safety Accommodate New policy Simple as Possible

14. Latest Evidence The Perioperative Management of Antithrombotic Therapy American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) James D. Douketis, MD, FRCP(C); Peter B. Berger, MD, FACP; Andrew S. Dunn, MD, FACP; Amir K. Jaffer, MD; Alex C. Spyropoulos, MD, FACP, FCCP; Richard C. Becker, MD, FACP, FCCP and Jack Ansell, MD, FACP, FCCP 1. Chest. 2008; 133:299S-339

16. Decision-Making Pathway Yes 1. Is the surgeon willing to operate on warfarin? Continue. Check INR is within required limits No 2. Does the patient require clexane bridging? (See risk assessment) Yes

17. Decision-Making Pathway Prophylactic clexane Yes Stop warfarin 5 days before surgery1 Therapeutic clexane No clexane 1. Chest. 2008; 133:299S-339

18. Clexane Bridging Safety (therapeutic bridging) Blood testing (INR)

19. Prophylactic Clexane 40mg OD

20. Arterial Risk Factors 1mg/kg BD Venous Risk Factors Therapeutic Clexane ? 1.5mg/kg OD

21. Atrial Fibrillation

22. Important Safety Points Renal failure – eGFR < 30 Therapeutic dosing with 1mg/kg OD am only Only 40mg the day before surgery Use lean body weight

23. Important Safety Points Renal failure – eGFR < 30 Body weight (low and high) Prophylaxis 20mg OD if < 50kg BMI >= 35 ? Lean body weight

24. Important Safety Points Renal failure – eGFR < 30 Body weight (low and high) Anti factor Xa levels

25. The Practicalities Linking with the community Self injecting Patient Information

26. Decision-Making 2 Yes Nurses can teach the patient or relative Patient picks up clexane prescription from hospital Patient information sheet Can the patient self-inject?

27. Self injecting

28. Decision-Making 2 Telephone GP Practice No Patient picks up clexane prescription from hospital Patient information sheet PCT Community prescription Can the patient self-inject?

29. Community Input Practice can help  Pre-assessment Acute GP service Surgical assessment unit Carefully plan day of surgery Practice can’t help Patient can’t get there Bridging over W/E

30. Patient Information

31. Patient Information

32. Any Other Pre-op instructions Remember not to take your insulin on the morning of the operation when you have nothing to eat Take your blood pressure tablets as usual. Patient Information

33. 49 yr old man. Needs a cystoscopy Dilated cardiomyopathy, EF 40%, valves ok AF on warfarin (stable INR) TIA 3 years ago Internal cardiac defibrillator Front of list 85kg, normal renal function Example 1

35. Wife will inject clexane Prophylactic clexane 40mg s/c Prescription and information sheet   

36. Example 2 85 year old lady 80 kg Needs cervical disc surgery Chronic renal failure eGFR 25 Warfarin for recurrent DVT and PE Wheelchair due to pain but husband mobile. No car. Front of list

38. e GFR <30 Clexane 1mg / kg OD 40 mg day before surgery Prescription and information sheet 80mg 80mg 40mg

39. Practicalities Feel they can’t cope with clexane injections GP practice know them well. Husband can push the wheelchair. Practice nurses happy to inject clexane. Clexane prescription, information leaflet and PCT prescription Patient will let practice know when she has a date and take paperwork to sort out plan

40. Extreme Bridging

41. Example 3 80 year old lady. 40kg. Lives alone Needs lumbar spine surgery Warfarin for mechanical mitral valve INR unstable at times Lives in Plymouth, has to get the bus to hospital Surgery scheduled for Tues (bridging a w/e) Worried about self-injecting

43. Therapeutic clexane 40mg BD Prescription and information sheet 40mg     omit

44. Practicalities Worried about clexane injections GP practice isn’t available over the weekend Unfair to get bus BD over the weekend What other option do we have?

45. Thank you, any questions?