Euroanaesthesia 2019 Antithrombotic therapy for eye - PowerPoint Presentation

Slide1

Euroanaesthesia 2019

Antithrombotic therapy for eye surgery- new approachesAssoc. Prof. Tatjana Šimurina MD, PhDGeneral Hospital Zadar; Dept. of Health Study, University of Zadar; Medical faculty, University of Osijek tsimurina@unizd.hr tatjana.simurina@mefos.hr

1

Conflict of interests declaration

No conflit of interest Old postcard: “ A blind man from Kotari”, Dalmatia, Croatia

2

Outline

thrombotic 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 proceduresCharacteristics of patients undergoing eye surgery Increasing tendency toward regional anesthesia for eye surgeryAmbulatory

care

(

Fast-track

anesthesia

)

Guidelines:

https://

www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-sci-247-local-anaesthesia-in-ophthalmic-surgery-2012.pdf

https://www.rcoa.ac.uk/system/files/gpas-2019-13-ophthal.pdfhttps://rapm.bmj.com/content/rapm/43/3/263.full.pdf

Horlocker TT et al. Reg Anesth Pain Med 2018;43:263–309

4

Expansion of ophthalmic ambulatory

anesthesiaContributing factors to the growth of ophthalmic ambulatory anesthesia minimally invasive eye-surgical techniquesimprovements in anesthesia techniques and pain controlcharacteristics of ophthalmic patient population economic pressures

5

Common

day-case eye surgeriesCataract extraction Strabismus repair Glaucoma surgeryNasolacrimal duct probingChalazion excision

Eye

examination

(

tonometry

)

Longer eye surgery + high risk of perioperative complications - not appropriate for

a

mbulatory

anesthesia Eye surgery – low risk (cardiac risk <1%)6

Indications

for antithrombotic therapy Stroke prevention in atrial fibrillation (AF) The management and prevention of thromboembolismMechanical heart valve (MHV)Treatment of acute coronary syndrome (ACS)Secondary prevention of cardiovascular disease

7

Risk

of hemorrhagic complicationsHigh - orbital and major oculoplastic surgeriesIntermediate - vitreoretinal, glaucoma, corneal transplant

Low

-

cataract

surgery

,

intravitreal

injections Surgical bleeding and needle block hemorrhage may be detrimental for visual function (limited surgical field in eye-surgery!)High/ intermediate risk surgery in a patient with A

p/Ac therapy - not appropriate for outpatient setting No evidence of increased bleeding risk in peribulbar/retrobulbar anesthesia - single shot inferonasal puncture with narrow and short needle8

R

isk stratification for bleeding in needle/ cannula blocks Comorbidity, Ac/Ap therapy

REGIONAL ANESTHESIA

PERIBULBAR/ RETROBULBAR

EPISCLERAL SUBTENON‘S BLOCK

HIGH

MODERATE

LOW

ASA I, no

therapy

LIVER/RENAL FAILURE, COAGULOPATHY

ANTIPLATELET

Ap

Prophylaxis

(single drug)

Primary

Secondary

DUAL

Ap

THERAPY

STOP ONE

Ap

ANTICOAGULANT Ac AF (for VKA INR 2.5)PE, DVT (for VKA INR 2.5)LONG TERM FOR RECURRENT PE/DVT/HIGH RIKS OF STROKE (for VKA INR 2.5)Ac +/- Ap MHV (for VKA INR 3.5)/ Ac + Ap MHV (for VKA INR 3.5)/ Ac+Ap + only ONE EYE

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

9

Needle

blocks in ophthalmic patients with(out) antithrombotic therapy –

risk

of

hemorrhage

Reference

Study

design Total n (Diagnosis or surgery) Anesthesia

Intervention

Control

Follow

up

/

Incidence

of

bleeding

(%)Severity of bleedingKallio grades* G (%)Results *Kallio H et al. Br J Anaesth 2000; 85:708-11Prospective cohort 1383 (1105= cataract/anterior segment disorders )Retrobulbar/peribulbar A1 warfarinAspirin stopped: A2 0-2 days A3 3-14 days B no antithrombotics 10 min postop.A1 3.9A2 5A3 3.2B 4.1G1 2.4G2/G3 1.6 G4 0No significant difference Katz J et al. Ophthalmology 2003;110:1784–8Prospective

cohort

19,283 CataractRetrobulbar and/or

peribulbar

anesthesia

, Topical LA Aspirin: A1 discontinued A2 continued Warfarin:A3 discontinuedA4 continued B1 no aspirin B2 no warfarin 7 daysA1, A3, A4 0A2 0.04B1 0.04 B2 0.04 Retrobulbar hemorrhage Medical and ophthalmic events – no significant difference Calenda E et al. Acta Anaesthesiol Taiwan 2011; 49:141-3 Prospective case control 1000 Cataract, Pterygium, Vitrectomy, Buckling and/or circling, Keratoplasty, Amniotic membranePeribulbar blockA: aspirin continuedB: no aspirin 24 hoursA 6 B 4.2 A: G1 6G2, G3, G4 0B: G1 4G2 1 patient G3, G4 0No significant difference Calenda E et al. Int J Ophthalmol 2014;7:110-3Prospective case control study1500 Cataract, Vitrectomy, Buckling and/or circling, Keratoplasty, Amniotic membranePeribulbar blockA: VKA continued B: no VKA 24 hoursA 2B 1.75A: G 1 1.74G2 0.26G 3 , G4 0 B: G1 1.6G2, G3 , G4 0 No significant difference

*

1 spot ecchymosis; 2 lid ecchymosis involving half of the lid surface area or less; 3 lid ecchymosis all around the eye, no increased IOP ; 4 retrobulbar hemorrhage with increased IOP

Takaschima A, et al. (2016) PLoS ONE11 (1): e0147227.

10

The risk of intra/postoperative hemorrhage

Older ageRenal/ liver failure, anemia, diabetesFamily history of (h/o) bleeding or clotting disorders

U

ncontrolled

hypertension

Atherosclerosis

H/o

thromboembolic

eventsCardiac stent Antithrombotics; Herbal treatmentEye

features (choroidal sclerosis, glaucoma, myopic eye, recent eye surgery) Type of eye surgery

(

cataract

surgery

-

minimal

risk

bleeding

)

http://www.cec.health.nsw.gov.au

/

11

R

isk stratification for bleeding in eye surgery RISK for bleeding HIGH MODERATE

LOW

Comorbidity

,

Ac/

Ap

therapy

CATARACTVITREORETINAL EYE LID

GLAUCOMA FILTRATION ORBITAL PRESEPTALPOSTSEPTAL / SKIN GRAFT/ LACRIMAL

ASA I, NO THERAPY

LIVER/ RENAL FAILURE, COAGULOPATHY

ANTIPLATELET

Ap

PROPHYLAXIS

(single drug)

PRIMARY

SECONDARY

DUAL

Ap

THERAPY

STOP ONE

Ap

ANTICOAGULANT

Ac AF (for VKA INR 2.5)

PE, DVT (for VKA INR 2.5)

LONG TERM FOR RECURRENT PE/

DVT/

HIGH RIKS OF STROKE (for VKA INR 2.5)Ac +/- Ap MHV (for VKA INR 3.5)/ Ac+Ap MHV (for VKA INR 3.5)/ Ac+Ap + only ONE EYE Kiire CA et al. Br J Ophthalmol 2014;98:1320-412

To stop

Ap/Ac or continue ? For most ophthalmic operations the risk of stopping antithrombotic therapy is higher than the risk of continuing antithrombotics !

Risk of surgical bleeding and vision

–

threatening

hemorrhage if

Ap

/Ac

continued

Risk of life-threatening thromboembolic events while discontinued or modified Ap/Ac therapy

13

To bridge or not to bridge ?The BRIDGE trial, randomized, double-blind, placebo-controlled, n=1884 from 2009-14, AF, warfarin therapy, surgery: gastrointestinal, cardiothoracic

,

orthopedic

Douketis

JD

et

al

.

Perioperative

Bridging Anticoagulation in

Patients with Atrial Fibrillation. N Engl J Med 2015;373(9):823–33. Outcome

(

primary

,

secondary

)

G

NB

(No Bridging)=918

,

n

(%)

GB (Bridging, LMWH)=895, n (%)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)0Systemic embolism 00Major 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 01 (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 14

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

fibr

i

llation

. 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 15

Keys

to successIndividualized approach Antithrombotics (novel drugs) Type of anesthesia Type of surgery - anterior or posterior segment of the eyeRenal function Multimodal approachConsultationCommunication16

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)

CONTINUED

Cataract

(RBA)

Chalazion

Eyelid

cyst

Lacrimal

probing

Dacryocystorhinostomy

Pterygium

Keratoplasty

Evisceration Enucleation Cerclage /indentation CONTINUEDAFTER HIGH THROMBOTIC RISK PERIOD 7 days: prasugrel 5 days: ticagrelor CONTINUE ASA Posterior segment:Retinal detachment Vitreoretinal surgery Vitrectomy CONTINUECONTINUE unless surgeon special request ANTIPLATELET THERAPY DISCONTINUED 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 Anaesthesiol 2013;30:449-5417

Anti

coagulant therapy in eye surgeryANTICOAGULANTS CAN BE CONTINUED

EYE SURGERY

Unfractionned

heparin

, UFH

LWMH

Fondaparinux

(

Arixtra

)VKA

Half life: SHORT LONG Cataract (topical)

CONTINUE

Cataract

(RBA)

Chalazion

Eyelid

cyst

Lacrimal

probing

Dacryocystorhinostomy

Pterygium

Keratoplasty Evisceration Enucleation Cerclage /indentation CONTINUECONTINUE (INR within therapeutic range)Posterior segment:Retinal detachment Vitreoretinal surgery Vitrectomy CONTINUE unless surgeon special request ANTICOAGULANTS DISCONTINUED / BRIDGING THERAPYGlaucomaEyelid entropion/ectropion/ptosis Orbital decompression 3 hours Last doseProphylaxis: 12 hTherapy: 2 doses /day: 24 h1 dose /day: 36 h

Last

doseProphylaxis: 24 h Therapy

: 36 h

INR <1,5

Last dose4 days ± BRIDGING UFH/LMWH Last dose 7 days / + Vitamin K± BRIDGING UFH/ LMWH Strabismus Bonhomme F. et al. Eur J Anaesthesiol 2013; 30:449-5418

D

irect oral anticoagulants in eye surgery ANTICOAGULANTS CAN BE CONTINUED EYE SURGERY DOACs at therapeutic doseDabigatran

(

Pradaxa

),

Rivaroxaban

(

Xarelto

),

Apixaban

(

Eliqius) …Cataract (topical)

CONTINUEDCataract (RBA) Chalazion Eyelid cyst Lacrimal probing DacryocystorhinostomyPterygium

Keratoplasty

Evisceration

Enucleation

Cerclage

/

indentation

AFTER

HIGH

THROMBOTIC RISK PERIOD

24 h before

RESTART 24 h after Posterior segment:Retinal detachment Vitreoretinal surgery Vitrectomy DOACs 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 Anaesthesiol 2013; 30:449-5419

Uyhazi

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;

M

ain

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

days

Anticoagulant

n (%)

210,428

Intraocular

hemorrhages

HR

(95% CI) P 90Warfarin 146,137 (69.4)81 (0.06)0.13Dabigatran / Rivaroxaban 64,291 (30.6)33 (0.05)0.73 (0.22-2.63)365Warfarin 146,137 (69.4)203 (0.14)0.03Dabigatran / Rivaroxaban 64,291 (30.6)92 (0.14)0.75 (0.58-0.97)

Antiplatelet

n

(%) Intraocularhemorrhages HR (95% CI )PClopidogrel 103,796(92.5)68 (0.07)0.55Prasugrel 8,386(7.5)5(0.06)0.75(0.29-1.92)Clopidogrel 103,796(92.5)134(0.13)0.53Prasugrel 8,386(7.5)16(0.19)1.19(0.69-2.04)20

Conclusions

Ophthalmic patients require specific approach depending on the type of eye surgery and anticoagulant treatment

Many

ophthalmic

procedures

for

outpatients

can

be safely performed while antithrombotic therapy

is continued For some ophthalmic outpatients, the risk of stopping antiplatelet and anticoagulant medications

may

outweigh

the

risk

of

peri-operative

hemorrhage

ʺ

O

ne size fits all” approach is not advisable and individualized approach is recommendedLocal protocols for each ambulatory eye-surgery centre 21