surgery new approaches Assoc Prof Tatjana Šimurina MD PhD General Hospital Zadar Dept of Health Study University of Zadar Medical faculty University of Osijek tsimurinaunizdh ID: 919723
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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
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Slide2Conflict of interests declaration
No conflit of interest Old postcard: “ A blind man from Kotari”, Dalmatia, Croatia
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Slide3Outline
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
Slide4Introduction
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
Slide5Expansion 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
Slide6Common
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
Slide7Indications
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
Slide8Risk
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
Slide9R
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
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Slide10Needle
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.
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Slide11The 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
Slide12R
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
Slide13To 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
Slide14To 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
Slide15Does
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
Slide16Keys
to successIndividualized approach Antithrombotics (novel drugs) Type of anesthesia Type of surgery - anterior or posterior segment of the eyeRenal function Multimodal approachConsultationCommunication16
Slide17Antiplatelet 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
Slide18Anti
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
Slide19D
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
Slide20Uyhazi
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
Slide21Conclusions
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