Evaluation of Bleeding Risk Prior to Invasive Procedures

2021 ◽  
pp. 411-422
Author(s):  
Andrea Lewin ◽  
Katelyn W. Sylvester ◽  
Jean M. Connors
Keyword(s):  
Bleeding Risk ◽  
Invasive Procedures

Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease

2020 ◽  
Vol 46 (06) ◽  
pp. 682-692
Author(s):  
Saro Khemichian ◽  
Norah A. Terrault
Keyword(s):  
Liver Disease ◽  
Chronic Liver Disease ◽  
Invasive Procedure ◽  
Bleeding Risk ◽  
Chronic Liver ◽  
Bleeding Complications ◽  
Invasive Procedures ◽  
Platelet Counts ◽  
Receptor Agonists ◽  
Platelet Transfusions

AbstractThrombocytopenia is one of the most common hematologic complications in cirrhosis. Despite limited data linking platelet count and bleeding risk in patients with cirrhosis, the use of platelets transfusions for invasive procedures has been a common practice. Recently, thrombopoietin (TPO) receptor agonists have been approved for use in patients with chronic liver disease (CLD) undergoing invasive procedures. The aim of this study was to review current literature on bleeding risk in patients with cirrhosis and the use of platelet transfusions and TPO receptor agonists in the context of invasive procedures. PubMed search was conducted to find articles relating to cirrhosis, thrombocytopenia, and new novel treatments for this condition. Search terms included CLD, cirrhosis, thrombocytopenia, bleeding, thrombosis, coagulopathy, hemostasis, and TPO receptor agonists. Romiplostim, eltrombopag, avatrombopag, and lusutrombopag are approved TPO receptor agonists, with avatrombopag and lusutrombopag specifically approved for use in patients with CLD undergoing invasive procedures. In patients with platelet counts < 50,000/mm3, avatrombopag and lusutrombopag increased the platelet counts above this threshold in the majority of treated patients and reduced the frequency of platelet transfusions. At the approved doses, incidence of thrombosis was not increased and therapies were well tolerated. Studies were not powered to assess whether risk of bleeding complications was reduced and the fundamental question of whether correction of thrombocytopenia is warranted in patients undergoing invasive procedures remains unanswered. The use of TPO receptor agonists has resulted in less requirement for platelet transfusions. In patients with cirrhosis undergoing invasive procedures for whom platelet transfusion is planned, TPO receptor agonists are an alternative and avoid the risks associated with transfusions. However, there is need for a thoughtful approach to manage bleeding risk in patients with cirrhosis undergoing procedures, with the consideration of a comprehensive hemostatic profile, the severity of portal hypertension, and the complexity of the invasive procedure to guide decisions regarding transfusions or use of TPO receptor agonists.

Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures.

2008 ◽  
Vol 140 (5) ◽  
pp. 496-504 ◽  
Author(s):  
Y. L. Chee ◽  
J. C. Crawford ◽  
H. G. Watson ◽  
M. Greaves
Keyword(s):  
Bleeding Risk ◽  
Invasive Procedures

scholarly journals The Use of Thrombopoietin Receptor Agonists for Correction of Thrombocytopenia prior to Elective Procedures in Chronic Liver Diseases: Review of Current Evidence

2016 ◽  
Vol 2016 ◽  
pp. 1-9 ◽  
Author(s):  
Kamran Qureshi ◽  
Shyam Patel ◽  
Andrew Meillier
Keyword(s):  
Liver Diseases ◽  
Bleeding Risk ◽  
Chronic Liver ◽  
Current Evidence ◽  
Severe Thrombocytopenia ◽  
Invasive Procedures ◽  
Chronic Liver Diseases ◽  
Platelet Counts ◽  
Thrombopoietin Receptor ◽  
Increased Risk

Patients with chronic liver diseases (CLD) undergo a range of invasive procedures during their clinical lifetime. Various hemostatic abnormalities are frequently identified during the periprocedural work-up; including thrombocytopenia. Thrombocytopenia of cirrhosis is multifactorial in origin, and decreased activity of thrombopoietin has been identified to be a major cause. Liver is an important site of thrombopoietin production and its levels are decreased in patients with cirrhosis. Severe thrombocytopenia (platelet counts < 60–75,000/µL) is associated with increased risk of bleeding with invasive procedures. In recent years, compounds with thrombopoietin receptor agonist activity have been studied as therapeutic options to raise platelet counts in CLD. We reviewed the use of Eltrombopag, Romiplostim, and Avatrombopag prior to various invasive procedures in patients with CLD. These agents seem promising in raising platelet counts before elective procedures resulting in reduction in platelet transfusions, and they also enabled more patients to undergo the procedures. However, these studies were not primarily aimed at comparing bleeding episodes among groups. Use of these agents had some adverse consequences, importantly being the occurrence of portal vein thrombosis. This review highlights the need of further studies to identify reliable methods of safely reducing the provoked bleeding risk linked to thrombocytopenia in CLD.

Prophylactic correction of the international normalized ratio in neurosurgery: a brief review of a brief literature

2011 ◽  
Vol 114 (1) ◽  
pp. 9-18 ◽  
Author(s):  
Kelly L. West ◽  
Cory Adamson ◽  
Maureane Hoffman
Keyword(s):  
Bleeding Risk ◽  
International Normalized Ratio ◽  
Fresh Frozen Plasma ◽  
Coagulation Cascade ◽  
Bleeding Tendency ◽  
Invasive Procedures ◽  
Clinical Tool ◽  
Clotting Factors ◽  
Fresh Frozen ◽  
Frozen Plasma

Prophylactic fresh-frozen plasma (FFP) transfusion is often undertaken in hemodynamically stable patients with a minimally elevated international normalized ratio (INR) prior to invasive procedures, despite little evidence in support of this practice. The authors review the current literature in an attempt to clarify best clinical practice with regard to this issue. Although the activated partial thromboplastin time and prothrombin time–INR are useful laboratory tests to measure specific clotting factors in the coagulation cascade, in the absence of active bleeding or a preexisting coagulopathy, their utility as predictors of overall bleeding risk is limited. Several studies have shown an imperfect correlation between mild elevations in the INR and subsequent bleeding tendency. Furthermore, FFP transfusion is not always sufficient to achieve normal INR values in patients who have mild elevations (< 2) to begin with. Finally, there are risks associated with FFP transfusion, including potential transfusion-associated [disease] exposures as well as the time delay imposed by laboratory testing and transfusion administration prior to initiation of procedures. The authors propose that the current concept of a “normal” INR value warrants redefinition to make it a more meaningful clinical tool. Based on their review of the literature, the authors suggest that in a hemodynamically stable patient population there is a range of mildly prolonged INR values for which FFP transfusion is not beneficial, and is potentially harmful.

Bleeding and Thrombotic Outcomes Following Perioperative Interruption of Direct Oral Anticoagulants in Patients with Prior Venous Thromboembolic Disease

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2614-2614
Author(s):  
Joseph Shaw ◽  
Carine de Wit ◽  
Gregoire Le Gal ◽  
Marc Carrier
Keyword(s):  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Thromboembolic Complication ◽  
Invasive Procedures ◽  
Bleeding Rate ◽  
Major Bleeding Rate ◽  
Venous Thromboembolic ◽  
Overall Mortality

Abstract Introduction: The use of Direct Oral Anticoagulants (DOACs) for the prevention and treatment of Venous Thromboembolic Disease (VTE) is increasingly common. Patients on longstanding anticoagulation for the prevention of VTE frequently undergo invasive procedures that necessitate interruption of anticoagulation in order to avoid excessive bleeding during the procedure. There is little evidence surrounding the safety of perioperative DOAC interruption in patients with VTE. Methods: This study represents a retrospective analysis of adult patients on DOAC therapy for prior VTE, who underwent temporary interruption of anticoagulation therapy for inpatient or outpatient invasive procedures. The timing to hold and resume DOAC anticoagulation was based on the estimated half-life of the DOAC, as well as the bleeding risk of the procedure (Standard vs High). Our primary outcomes included the 30-day thromboembolic complication rate, as well as the 30-day major bleeding rate (ISTH non-surgical and surgical major bleeding criteria). Secondary outcomes included clinically relevant non-major bleeding (CRNMB) and overall mortality. Results: To date, a total of 87 patients have been included in the analysis, 68% of which were male. The mean age of the cohort was 58.3 years. All patients were on DOAC anticoagulation for acute treatment or secondary prevention of recurrent VTE. A large majority of patients (94%) were anticoagulated with rivaroxaban. Procedures were performed on an inpatient or outpatient basis in 24 and 63 patients, respectively. Forty six patients underwent procedures with standard bleeding risk. Mean time to anticoagulation discontinuation for standard and high bleeding risk procedures was 41.3 (SD = 20.8) and 49.3 (SD = 17.7) hours, respectively. The 30-day thromboembolic complication rate was 1.2% (95% CI: 0.2 to 6.2%), whereas the 30-day major bleeding rate was 0% (95% CI: 0 to 4.2%). The rate of CRNMB was 3.5% (95% CI: 1.2 to 9.7%). Overall mortality was 0% (95% CI: 0 to 4.2%). Conclusion: The perioperative interruption of direct oral anticoagulation for invasive procedures in patients with prior VTE appears to be associated with a relatively low risk of major bleeding, as well as recurrent VTE. Prospective studies are needed to evaluate the benefits and risks of perioperative interruption of direct oral anticoagulation in patients with prior VTE. Disclosures Carrier: BMS: Research Funding; Leo Pharma: Research Funding.

Bleeding Risk after Invasive Procedures in Aspirin/NSAID Users: Polypectomy Study in Veterans

2012 ◽  
Vol 125 (12) ◽  
pp. 1222-1227 ◽  
Author(s):  
Divey Manocha ◽  
Mandeep Singh ◽  
Nilesh Mehta ◽  
Uma K. Murthy
Keyword(s):  
Bleeding Risk ◽  
Invasive Procedures

Invasive procedures in the outpatient setting: Managing the short-acting acenocoumarol and the long-acting phenprocoumon

2007 ◽  
Vol 98 (10) ◽  
pp. 747-755 ◽  
Author(s):  
Barbara Hutten ◽  
Nathalie Péquériaux ◽  
Hanneke de Vries-Goldschmeding ◽  
Emmy Räkers ◽  
Marcel Levi ◽  
...  
Keyword(s):  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Invasive Procedure ◽  
Bleeding Risk ◽  
Coagulation Factors ◽  
Outpatient Setting ◽  
Similar Proportion ◽  
Invasive Procedures ◽  
The Mean ◽  
Long Acting

SummaryTreatment with vitamin K antagonists (VKAs) has to be interrupted when invasive procedures are planned. We compared various methods of interruption in patients on acenocoumarol or phenprocoumon in a prospective study. In patients on acenocoumarol (n=141), 99 stopped three days before the intervention and 42 stopped two days before. All patients on phenprocoumon (n=111) received vitamin K two days before the intervention, and 55 of these patients discontinued phenprocoumon, whereas 56 did not stop. In a subset of 30 patients we determined International Normalized Ratios (INRs) and coagulation factors II,VII, X and protein C. The mean INR after stopping acenocoumarol for three days was significantly lower than after two days (1.1 vs. 1.3, p=<0.0001), but its clinical relevance may be trivial. In patients using phenprocoumon, the mean INR on the day of the intervention was only slightly lower after stopping the VKAs (1.5 vs. 1.6, p=0.0407), but a similar proportion of patients had an INR ≤1.4. On the day of the intervention, in the acenocoumarol group mean plasma levels of all coagulation factors were higher than 50% and in the phenprocoumon group higher than 25%. We conclude that acenocoumarol can be stopped two days before an invasive procedure that is associated with a low or moderate bleeding risk and three days before an intervention with a higher bleeding risk. For phenprocoumon, administration of vitamin K two days before an intervention results in an acceptable INR during the intervention, regardless whether phenprocoumon is interrupted or not.

scholarly journals Incorporation of Evidence Based Guidelines on Bleeding Risk Assessment PRIOR to Ent Surgery into Practice: Real Time Experience

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4714-4714
Author(s):  
Nada Al-Marhoobi ◽  
Manar Maktoom ◽  
Fatma Bulushi ◽  
Mohamed Ebrahim Mohamed Ebrahim Elshinawy ◽  
Hanan Nazir ◽  
...  
Keyword(s):  
Bleeding Risk ◽  
Bleeding Tendency ◽  
Invasive Procedures ◽  
Coagulation Profile ◽  
Awareness Campaigns ◽  
Laboratory Test Results ◽  
Coagulation Testing ◽  
History Of ◽  
British Committee ◽  
Bleeding History

Abstract Background: In spite of guidelines recommending the no need for coagulation profile prior to ENT surgeries when challenging history of bleeding is negative, yet surgeons still practice it. Cost and delaying surgeries are major issues faced when insignificant abnormalities are found in the coagulation profile results. In 2008, British Committee for Standards of Hematology has published guidelines (1) on assessing the bleeding risk prior to surgeries or invasive procedures, which stated that the indication for sending a coagulation profile is best based on the bleeding history of the patient. Aim: This study aimed to measure unbiased estimate of hemostatic outcomes in ENT surgeries in relation to coagulation testing. Methods: All patients who underwent ENT surgeries from three tertiary hospitals during the period from 1st July 2016 to 1st January 2017 were enrolled in the study. The retrieved data included gender, age, type of surgery, results of coagulation blood test (if done), other laboratory test results (complete blood count, biochemical profile, etc.), postoperative bleeds, how it was managed, need for blood transfusion and whether the patient required another surgery to stop the bleeding or not. Patients with known bleeding history or previous coagulation derangement were excluded from the study. The primary outcome was post-operative bleeding. Results: The study included data from 730 patients who underwent ENT surgical procedures. They were 432 males and 298 females. Their mean age was 19.6 + 16.92 year. Out the 730 patients, 372 patients were interviewed for a challenging bleeding history alone (group 1) and 358 were interviewed plus a pre-operative coagulation profile check (Group 2). Total of fourteen patients (1.9 %) developed postoperative bleeding. None of them was due to abnormal bleeding tendency and they didn't require any hemostatic support. Six of them bled early (primary hemorrhage) while at the hospital due to surgical reasons (surgical site bleed that required suturing). Eight patients had delayed postoperative bleeds, after being discharged (due to eating hard food/Trauma). Only total of four patients had major bleeds, requiring surgical intervention. Conclusion: Despite guidelines recommending not doing coagulation testing prior to surgeries, many local surgeons still consider preoperative coagulation testing as a standard practice to evaluate the patients bleeding risk prior to any surgical procedure. This has resulted in unnecessary delays in surgeries (reaching up to a year in many patients) besides the parents/patients anxiety and additional total cost. We recommend awareness campaigns for surgeons and adhering to guidelines of taking detailed hemostatic history. Reference: Chee YL1, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008 Mar;140(5):496-504. Keywords: Coagulation testing, Bleeding History, Surgery Disclosures No relevant conflicts of interest to declare.

scholarly journals Factor XIII Deficiency in Patients with Acute Leukemia: One out of Three Is Presenting with Deficiency

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1528-1528 ◽  
Author(s):  
Elisabetta Vagge ◽  
Christian Dornes ◽  
Maisun Abu Samra ◽  
Wolfgang Blau ◽  
Mathias J Rummel ◽  
...  
Keyword(s):  
Acute Leukemia ◽  
Intracranial Hemorrhage ◽  
Factor Xiii ◽  
Bleeding Risk ◽  
Bleeding Complications ◽  
Invasive Procedures ◽  
Risk Of Bleeding ◽  
Median Level ◽  
High Bleeding Risk ◽  
Fxiii Deficiency

Abstract Introduction: Factor XIII (FXIII) is a coagulation factor, playing an important role in the coagulation process by keeping the hemostatic clot and allowing tissue repair. The incidence of FXIII deficiency in acute leukemia is not well characterized. FXIII deficiency is known to have a high bleeding risk and cannot be detected by lab evaluation of aPTT and/or INR levels. In combination with thrombocytopenia in patients (pts) presenting with acute leukemia, FXIII deficiency increases bleeding risk (for example in invasive procedures or for intracranial hemorrhage). In 2013 a study was conducted in 9 pediatric pts (6 acute leukemias, 1 burkitt, and 2 solid tumors) in whom FXIII deficiency was found. These pts had bleeding complications that were resolved by FXIII concentrate substitution (Wiegering. V. et al. Haematologica, June, 10, 2013).Patients affected from AML and ALL could easily be screened at diagnosis regarding FXIII level. In the setting of newly diagnosed acute leukemia pts in whom thrombocytopenia is frequently occurring, a preemptive substitution of FXIII could be considered in order to reduce the risk of bleeding complications. Methods: In this retrospective analysis (Jan. 2009 to June 2014) we identified a total of 103 ptspresentingwithnewly diagnosed acute leukemia in whom we assessed FXIII level. In 95 pts FXIII level was available at initial diagnosis of acute leukemia and during treatment. Substitution of FXIII concentrate have been used in case of factor’s deficiency below 70% (normal range 70%-130%). Results: Patients presented withAML (64 primary AML and 20 secondary AML), or ALL (10), or 1 AUL. Median age was 67 years (range: 25-95). Thirty-four pts (35.8%) were younger than 60 years, 61 pts (64.2 %) were older than 60 years. FXIII deficiency was found in 35/95 pts (36.8%) with a median level of 49% (range: 21%-68%). Of those 35 pts with FXIII deficiency 33 had AML (1 AML M0, 9 AML M1, 2 AML M1/2, 5 AML M2, 6 AML M4, 5 AML M5). All pts (5/95) with AML M3 showed a deficiency with a median level of 28%. A level below 70% could be found in 7 out of 13 FLT3-ITD positive pts (53.8%) and in 7 out of 24 NPM1 positive pts (29.2 %). Median FXIII level was 34% for FLT3-ITD positive pts, respectively 30% for NPM1. FXIII substitution in deficient pts was well tolerated and effective. No patient showed intracranial hemorrhage. In addition, invasive procedures like bone marrow biopsy and central line insertion were possible without clinically relevant bleeding complications. In responding pts achieving remission following chemotherapy, a trend towards higher concentration of factor XIII during treatment was observed. Conclusions: Patients affected by AML or ALL are presenting usually with thrombocytopenia and have a high bleeding risk. In case of FXIII deficiency, risk of bleeding is increased potentially leading to a higher leukemia-related morbidity and mortality. Detection of FXIII deficiency is an established method and routinely available. Substitution of FXIII decreases the risk of bleeding and can reduce leukemia associated morbidity and mortality. In our study FXIII deficiency occurred in more than a third of our pts, including all AML M3 patients. We found a trend for more FXIII deficiency in FLT3-ITD high risk group patients. We suggest screening at diagnosis and during treatment of all acute leukemia pts and FXIII substitution in case of deficiency. To evaluate further the role of FXIII assessment and substitution in case of FXIII deficiency in acute leukemia, a prospective trial should be considered. Disclosures No relevant conflicts of interest to declare.

A Clinician’s Guide to Perioperative Bridging for Patients on Oral Anticoagulation

2010 ◽  
Vol 23 (4) ◽  
pp. 303-312 ◽  
Author(s):  
Michelle T. Martin ◽  
Ann M. Kuchta ◽  
Edith A. Nutescu
Keyword(s):  
Risk Stratification ◽  
Oral Anticoagulation ◽  
Oral Anticoagulant Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
Invasive Procedures ◽  
Bridging Therapy ◽  
Thrombosis Risk ◽  
Perioperative Anticoagulation ◽  
Risk Of Hemorrhage

Updates in recent clinical guidelines have led to a change in the management of perioperative anticoagulation for patients on oral anticoagulant therapy. No standardized bridging consensus exists in the literature. The necessity for bridging therapy is determined based on careful consideration of the thrombosis risk versus the bleeding risk of the procedure. Risk stratification will aid the decision to bridge or not to bridge. Patients are bridged with agents with appropriate kinetics to allow for their elimination prior to the time of the procedure in order to decrease the risk of hemorrhage during invasive procedures. This intent of this article is to discuss perioperative bridging therapy and provide a practical guide for the clinician.

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