Antithrombotic therapy in outpatients undergoing eye surgery under regional anesthesia - PowerPoint Presentation

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Antithrombotic therapy in outpatients undergoing eye surgery under regional anesthesia - new approaches

Associate Prof Tatjana Šimurina MD, PhDGeneral Hospital Zadar; Dept. of Health Study, University of Zadar; Assist Prof - Medical faculty, University of Osijek tsimurina@unizd.hr tatjana.simurina@mefos.hr

8th Croatian-European-American Anesthesiology Conference, HDARIM, May 23-26, 2019. Plitvice Lakes, Croatia

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Conflict of interests

None Old postcard:

“ A blind man from Kotari”, Dalmatia, Croatia2

outlinethrombotic

risk related to modification of antithrombotic therapy before eye-surgery risk of intraoperative and postoperative bleeding

associated with continuation of antithrombotic therapyapproach to ophthalmic patients on preoperative antithrombotic treatment 3

Introduction

Continuous trend of increased eye surgery patient characteristics Elderly Co-morbidities Taking medications Antithrombotic

agents (anticoagulants / antiplatelets , ac/Ap) : >28% aspirin, 2% clopidogrel; >5% anticoagulantsIncreasing tendency toward regional anesthesia (>95%) for

eye surgery

orbital NEEDLE blocks:

retrobulbar (intraconal),

peribulbar

(

Extraconal

)

cannula

block

(

episcleral

subtenon‘s)subconjunctival or topical (intracameral) anesthesia Guidelines: https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-sci-247-local-anaesthesia-in-ophthalmic-surgery-2012.pdfhttps://www.rcoa.ac.uk/system/files/gpas-2019-13-ophthal.pdfhttps://rapm.bmj.com/content/rapm/43/3/263.full.pdfHorlocker TT et al. Reg Anesth Pain Med 2018;43:263–309

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Expansion of ophthalmic ambulatory anesthesia (AA)

Contributing factors to the growth of ophthalmic AAminimally invasive eye-surgical techniquesimprovements in anesthesia techniques and pain controlcharacteristics of ophthalmic patient population economic pressuresWith permission from WMG Health5

Common day-case eye surgeries

Cataract extraction Strabismus repair Glaucoma surgeryNasolacrimal duct probingChalazion excisionEye

examination (tonometry)Longer eye surgery + high risk of perioperative complications - not appropriate for Ambulatory anesthesia Eye surgery – low risk (cardiac risk <1%)* *De Hert S, Imberger

G, Carlisle

J, et al.

Eur J

A

naesthesiol

2011;28:684-722

6

Indications for antithrombotic therapy

Stroke prevention in atrial fibrillation (AF) The management and prevention of thromboembolism Mechanical heart

valve (MHV)Treatment of acute coronary syndrome Secondary prevention of cardiovascular disease 7

Risk of hemorrhagic complications

High - orbital and major oculoplastic surgeriesIntermediate - vitreoretinal, glaucoma, corneal transplant Low - cataract surgery, intravitreal injections Surgical bleeding and needle block hemorrhag

e CAN be detrimental for visual function (limited surgical field in ocular surgery) High/ intermediate risk surgery + needle block in a patient with ap/ac therapy - not appropriate for outpatient setting no evidence of increased bleeding risk in peribulbar

/retrobulbar anesthesia

single shot inferonasal puncture

/ narrow, short needle/

small

incision

8

risk stratification for bleeding

in needle and cannula blocks Comorbidity, Ac/Ap

therapy REGIONAL ANESTHESIA PERIBULBAR OR RETROBULBAR EPISCLERAL (SUBTENON‘S BLOCK) RISK for bleeding

HIGH MODERATE

LOW

ASA

I, no

therapy

LIVER/RENAL FAILURE, COAGULOPATHY

ANTIPLATELET,

Ap

PRIMARY PROPHYLAXIS (SINGLE

DRUG)

SECONDARY PROPHYLAXIS (SINGLE DRUG) DUAL Ap THERAPY: STOP ONE Ap

DUAL

Ap

THERAPY

ANTICOAGULANT, Ac

ATRIAL FIBRILLATION,

AF (for

warfarin

INR 2.5)

PULMONAR

EMBOLISM (PE), DEEP VEIN THROMBOSIS (DVT)

(for

warfarin

INR 2.5)

LONG TERM FOR RECURRENT

PE/DVT/HIGH RIKS OF STROKE (for

warfarin

INR 2.5)Ac +/- Ap MHV (warfarin INR 3.5) or Ac + Ap MHV (warfarin INR 3.5) or Ac+Ap and ONLY ONE EYE

Kiire CA et al. Br J Ophthalmol 2014;98:1320-4. 

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The risk of

intra/postoperative hemorrhage Older ageLIVER/ renal FAILURE, ANEMIA, DIABETESUNCONTROLLED HYPERTENSION; ATHEROSCLEROSIS; CARDIAC STENT family History of (H/o) bleeding or clotting disordersH/o

thromboembolic eventsAntithrombotics, Steroids and herbal treatmentEye features: choroidal sclerosis, glaucoma, myopic eyeType of

eye surgeryrecent

eye surgery

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risk stratification for bleeding in eye

surgery RISK for bleeding HIGH

LOW MODERATEComorbidity, Ac/Ap therapy CATARACT VITREORETINAL

EYE LID

GLAUCOMA FILTRATION

ORBITAL

PRESEPTAL

POSTSEPTAL /SKIN GRAFT /LACRIMAL

ASA I, no

therapy

LIVER/RENAL FAILURE, COAGULOPATHY

ANTIPLATELET,

Ap

PROPHYLAXIS (SINGLE DRUG)

PRIMARY

SECONDARY

DUAL

Ap

THERAPY

-

STOP ONE

Ap

DUAL

Ap

THERAPY

ANTICOAGULANT, Ac

ATRIAL FIBRILLATION, AF (for warfarin INR 2.5)

PULMONAR EMBOLISM (PE), DEEP VEIN THROMBOSIS (DVT) (

warfarin

INR 2.5)

LONG TERM FOR RECURRENT PE/DVT/

HIGH RIKS OF STROKE (warfarin INR 2.5)

Ac

+/-

Ap

MHV (

warfarin INR 3.5) or Ac + Ap MHV (warfarin INR 3.5) or Ac+Ap and ONLY ONE EYE

Kiire CA et al. Br J Ophthalmol 2014;98:1320-4

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To stop Ap/Ac

or continue ? Risk of life-threatening thromboembolic events while

discontinued or modified Ap/Ac therapyRisk of surgical bleeding and vision –threatening

hemorrhage if

Ap/Ac

continued

For most ophthalmic

operations

the risk of stopping antithrombotic therapy is higher than

th

e

risk

of continuing antithrombotics. . 12

To bridge or not to bridge ?

The BRIDGE trial, randomized, double-blind, placebo-controlled N=1884 (2009- 2014), AF, warfarin therapy, surgery: gastrointestinal

, cardiothoracic, orthopedicDouketis JD et al. Perioperative Bridging Anticoagulation in Patients with AtrialFibrillation. N Engl J Med 2015;373(9):823–33.

Outcome

(

primary

secondary

)

G

NB

(No

Bridging

)

=

918 N (%) GB (Bridging, LMWH) =895N (%)PArt. thromboembolism 4 (0.4) 3 (0.3) 0.01* 0. 73†Stoke 2 (0.2)3 (0.3)

Transient

ischemic

attack

2 (0.2)

0

Systemic

embolism

0

0

Major

bleeding

12 (1.3)29 (3.2) 0.005†Death 5 (0.5)4 (0.4)0.88†Myocardial infarction 7 (0.8)

14 (1.6)

0.10†

Deep-vein

thrombosis

0

1 (0.1)

0.25†Pulmonary embolism 01 (0.1)0.25†Minor bleeding 110 (12.0) 187 (20.9)<0.001†*P for noninferiority † P for superiority 13

does my ophthalmic

patient need bridging therapy?Clinical scenario A 60-year-old man with normal renal

function has been taking NOAC dabigatran for prevention of stroke in non-valvular atrial fibrillation. He was scheduled to have combined phacoemulsification

with trabeculectomy

 in ambulatory

setting under

intraconal

/

extraconal

block

.

high

bleeding

risk was presumed and Noac was stopped 48 hours before procedure and resumed 24 hours after complete hemostasis.14

Keys to success

Individualized approach AntithromboticS (novel drugs) type of anesthesia Type of eye-surgery renal

function Multimodal approachconsultationCommunication15

Antiplatelet therapy

in eye surgeryANTIPLATELET THERAPY CONTINUED

EYE SURGERY COX-1 inhibitor ASA (Aspirin) ADP P2Y12 inhibition

Clopidogrel (

Plavix

) Prasugrel

(

Effient

)

Ticagrelor

(

Brilique

)

Cataract

(topical)CONTINUE Cataract (RBA) Chalazion Eyelid cyst Lacrimal probingDacryocystorhinostomyPterygiumKeratoplasty Evisceration

Enucleation

Cerclage

/

indentation

CONTINUE

AFTER

HIGH

THROMBOTIC RISK PERIOD

7 days:

prasugrel

5 days:

ticagrelor CONTINUE ASA Posterior segment:Retinal detachment Vitreoretinal surgery Vitrectomy CONTINUECONTINUE

unless

surgeon special

request

ANTI

PLATELET THERAPY

DISCONTINU

ED Glaucoma Eyelid-entropion, ectropion, ptosisOrbital decompression Prevention: Primary: 3 days Secondary: CONTINUE AFTER HIGH THROMBOTIC RISK PERIOD 5 days CONTINUE / + ASA Strabismus CONTINUE

Bonhomme F.

et al.

Eur

J

Anaesthesiolo

2013; 30:449-54

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AntiCoagulant therapy

in eye surgeryANTICOAGULANTS CAN BE CONTINUED

EYE SURGERY Unfractionned heparin, UFHLWMH Fondaparinux

(Arixtra)

VKA

Half

life

SHORT

LONG

Cataract

(

topical

)

CONTINUE Cataract (RBA) Chalazion Eyelid cyst Lacrimal

probing

Dacryocystorhinostomy

Pterygium

Keratoplasty

Evisceration

Enucleation

Cerclage

/

indentation

CONTINUE

CONTINUE (INR within therapeutic range)Posterior segment:Retinal detachment Vitreoretinal surgery Vitrectomy CONTINUE unless surgeon special

request

ANTICOAGULANTS

DISCONTINUED

before

eye

surgery / BRIDGING THERAPYGlaucomaEyelid entropion/ectropion/ptosis Orbital decompression 3 hours Last doseProphylaxis: 12 hTherapy: 2 doses /day: 24 h1 dose /day: 36 hLast doseProphylaxis: 24 h Therapy: 36 hINR <1.5

Last

dose

4

days

± BRIDGING:

UFH/LMWH

Last

dose

7

days

or

+ Vitamin

K

± BRIDGING:

UFH/ LMWH

Strabismus

Bonhomme

F.

et

al

.

Eur

J

Anaesthesiolo 2013; 30:449-54

17

DirECT ORAL antiCoagulanTS IN EYE SURGERY

ANTICOAGULANTS CAN BE CONTINUED EYE SURGERY

DIRECT ORAL ANTICOAGULANTS NOACs at therapeutic doseDabigatran (Pradaxa), Rivaroxaban (Xarelto), Apixaban (

Eliqius) …

Cataract (

topical)

CONTINUED

Cataract

(RBA)

Chalazion

Eyelid

cyst

Lacrimal probing DacryocystorhinostomyPterygiumKeratoplasty Evisceration Enucleation Cerclage /indentationAFTER HIGH THROMBOTIC RISK PERIOD 24 h beforeRESTART 24 h after

Posterior

segment:

Retinal

detachment

Vitreoretinal

surgery

Vitrectomy

NOAC at

therapeutic

dose DISCONTINUED / BRIDGING THERAPYGlaucomaEyelid entropion/ectropion/ptosis Orbital decompression Last dose 5 days± BRIDGING: UFH/LMWH Strabismus Bonhomme F. et al. Eur

J Anaesthesiolo 2013; 30:449-54

18

U

yhazi KE et al. association of novel oral antithrombotics with the risk of intraocular bleeding. JAMA Ophthalmol 2018;136:122-30.Retrospective cohort study,

national insurance claims database from 2010-2015; Main outcome: hazard ratio (HR) of developing intraocular hemorrhage at 90 and 365 days, 2 parallel analyses: Dabigatran

or

rivaroxaban

vs

Warfarin

Prasugrel

vs

Clopidogrel

Analysis

day

Anticoagulant

n(%) 210,428Intraocularhemorrhage HR (95% CI) PAntiplatelet n(%) Intraocular

hemorrhage

HR

(95% CI)

P

90 d

Warfarin

146,137 (69.4)

81

(0.06)

Reference

1

0.13

Clopidogrel

103,796

(92.5)68 (0.07)Reference 10.55Dabigatran / rivaroxaban 64,291 (30.6)33(0.05)0.73 (0.22-2.63)

Prasugrel

8,386

(7.5)

5

(0.06)

0.75

(0.29-1.92)

365 dWarfarin 146,137 (69.4)203 (0.14)Reference 10.03Clopidogrel 103,796(92.5)134(0.13)Reference 10.53Dabigatran / rivaroxaban 64,291 (30.6)92 (0.14)0.75 (0.58-0.97)Prasugrel

8,386(7.5)

16(0.19)

1.19

(0.69-2.04)

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ConclusionS

Regional anesthesia can safely be applied to most outpatients eye surgery procedures with continued antithrombotic therapyModification of perioperative antithrombotic therapy in ophthalmic patients requires a multidisciplinary approach Anesthesiologist has a leading role in preventing and resolving complications in ophthalmic

regional anesthesiaʺone size fits all approach” is not advisable for ophthalmic patients on Ap/Ac therapy and individualized approach is recommendedlocal protocols to minimize antithrombotic discontinuation and

thrombotic events, are

highly recommended

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T 60 H A N 50 k s f o r 40

A T T E N T i 30 o n d o y o u H

A

v 20

E

a

n

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u

E s t i o N s 10 21