Title: Perioperative Management of Patients on Anticoagulants Using
Thrombosis Risk Score
Maria Manaloto-Angeles, MD; David Wong, MD; Erik Yeo, FRCPC; Philip Peng, FRCPC; Teresa Cordes, RN; Frances Chung, FRCPC.
Departments of Anesthesia and Hematology, Toronto Western Hospital, University Health Network, University of Toronto.

INTRODUCTION: When patients on coumadin present for surgery, the perioperative management requires a balance between bleeding and clotting. Literatures suggest different management pathways. Based on review of literature and a local consensus panel, a Thrombosis Risk score (TRS) was derived. This study aims to evaluate the feasibility and safety of our management strategy using the TRS.
METHODS: The TRS assigned points to cardiac and non-cardiac factors according to their
thromboembolic risk (Table). A final score was determined by adding the individual components. Patients were classified as high-risk (>3) or low-risk (<3) for thromboembolism. All patients had their coumadin stopped for 5 days preoperatively. High-risk patients were given low-molecular-weight heparin (LMWH) to bridge the gap while the low-risk patients were not. Coumadin was re-started in both groups 24h after the operation if there was no bleeding. In the high-risk group, LMWH was also re-started until the target INR was achieved. With institutional REB approval, a three year retrospective chart review was done for patients utilizing this management strategy. Two complications which occurred within a two-week postoperative period were recorded: (1) thromboembolism (stroke, arterial or deep venous thrombosis) and (2) hematoma or bleeding in the surgical site requiring re-exploration or blood transfusion.
RESULTS: A total of 104 patients were reviewed. The two most common indications for coumadin are atrial fibrillation (44%) and mechanical heart valve (23%). The mean age was 68±13 years. 43% comprised orthopedics and 28% general surgical procedures. 89 belonged to the high-risk group, 15 to the low-risk group. All high-risk patients were compliant to LMWH therapy. Bleeding occurred in 1 patient (1.1%) in the high-risk group in the form of hematuria, which required blood transfusion. In the low-risk group, 1 patient had hematoma (6.6%), which was surgically re-explored. There was one incidence of scrotal hematoma and one hemarthrosis in the high-risk group not requiring intervention. There was no incidence of thromboembolism.
DISCUSSION: Over a three-year period, perioperative management strategy utilizing the TRS was found to be feasible with acceptable rates of bleeding complications. There were no perioperative thromboembolic complications.
REFERENCES:
1. Arch Intern Med 64:1319-26
2. Anaesth Intensive Care 31:145-54

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