Peri-Procedure Management of Antiplatelet Therapy
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Peri-Procedure Management of Antiplatelet Therapy Page 1 of 17 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. TABLE OF CONTENTS Interventional Spine/Pain Procedures and Regional Anesthesia Procedures…………………..……..…….…..…………. Page 2 All Other Procedures.……………………………………………………………..……..…….…..……………………………Page 3 APPENDIX A: Procedure Bleeding Risk…………………………….………………………………………………………..Pages 4-9 APPENDIX B: Procedure Bleeding Risk and Management of Antiplatelet Therapy for Interventional Spine and Pain Procedures.…….…………………………………….…….…..………………………………………………Pages 10-11 APPENDIX C: Management of Antiplatelet Therapy for Regional Anesthesia (neuraxial and deep peripheral nerve procedures, including lumbar puncture)..……………………………………………….……….…............ Page 12 APPENDIX D: Management of Antiplatelet Therapy for Other Procedures…………………………………………........Page 13 APPENDIX E: Recommendations for Delaying Elective Procedures……………………………………………………….Page 14 Suggested Readings..……………………………………………………………………………………………………………Pages 15-16 Development Credits...………………………………………………………………………………………………………….Page 17 Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 06/15/2021 Peri-Procedure Management of Antiplatelet Therapy Page 2 of 17 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. PRESENTATION EVALUATION MANAGEMENT PRE- AND POST-PROCEDURE (Inpatient or Outpatient) Interventional spine and See Appendix B for Reverse antiplatelet therapy, if indicated, pain procedures restart recommendations by transfusing 1 pooled unit of platelets Yes immediately before procedure and re-dose Interventional spine as needed for ongoing bleeding Regional anesthesia and pain procedures (neuraxial and peripheral See Appendix C for or nerve procedures including restart recommendations Urgent/ Regional anesthesia lumbar puncture) emergent (neuraxial and procedure? peripheral nerve ● See Appendix B to determine bleeding risk and management of antiplatelet therapy procedures including for interventional spine and pain procedures Yes lumbar puncture) ● See Appendix C for management of antiplatelet therapy for regional anesthesia Patient on (neuraxial and peripheral nerve procedures including lumbar puncture) antiplatelet No therapy Is scheduled for Consider delaying patient on ● See Appendix B to determine bleeding risk and procedure1 elective procedures, antiplatelet management of antiplatelet therapy if indicated (see therapy for primary ● If patient is on aspirin, aspirin/dipyridamole and/or 2 Interventional Appendix E) prevention ? P2Y12 inhibitor, the decision to hold antiplatelet spine and pain therapy should be made after discussion with Benign procedures Hematology, Cardiology, Interventional Radiology, Vascular Surgery or other appropriate service depending on the indication for antiplatelet therapy No ● See Appendix C for management of antiplatelet Other procedures, Regional anesthesia therapy see Page 3 (neuraxial and ● If patient is on P2Y12 inhibitor, the decision to peripheral nerve hold should be made after discussion with Benign Hematology, Cardiology, Interventional Radiology, 1 procedures including For patients on anticoagulant therapy, see the Peri-Procedure Management of Anticoagulants algorithm lumbar puncture) Vascular Surgery or other appropriate service 2 No history of stroke or myocardial infarction (MI) depending on the indication for antiplatelet therapy Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 06/15/2021 Peri-Procedure Management of Antiplatelet Therapy Page 3 of 17 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. MANAGEMENT PRE- AND POST-PROCEDURE Other Procedures Continue current antiplatelet therapy Reverse antiplatelet therapy, if indicated, Yes by transfusing 1 pooled unit of platelets See Appendix D for restart recommendations immediately before procedure and Low re-dose as needed for ongoing bleeding ● Continue aspirin for both moderate and high risk bleeding procedures bleeding ● Consult Benign Hematology, Cardiology, or Interventional Radiology, risk1? Yes or Vascular Surgery as indicated if patient on P2Y12 inhibitor No ● For Neurosurgery, Vascular Surgery, and high risk Ophthalmology Yes procedures, consult the respective team for peri-operative antiplatelet Urgent/ management Stent emergent ● For management of other agents, see Appendix D procedure? < 1 year? 2 No ● Continue aspirin for both moderate and high risk bleeding procedures No ● For Neurosurgery, Vascular Surgery, and high risk Ophthalmology Yes procedures, consult the respective team for peri-operative antiplatelet Does the Consider delaying management patient have a elective procedures, ● For management of other agents, see Appendix D if indicated (see coronary/carotid/ Appendix E) intracranial Primary prevention (no history of stroke or MI) stent? No ● Manage antiplatelet therapy according to Appendix D ● For patients undergoing carotid stent placement and on aspirin and/or P2Y12 inhibitor, do ASCVD = atherosclerotic cardiovascular disease not hold antiplatelet therapy prior to procedure CAD = coronary artery disease Secondary prevention (history of stroke, CAD/MI, CVD, PVD, venous or arterial thrombosis) CV = cardiovascular 2 CVD = cardiovascular disease ● Continue aspirin for both moderate and high risk bleeding procedures MI = myocardial infarction ● For Neurosurgery, Vascular Surgery, and high risk Ophthalmology procedures, consult the PVD = peripheral vascular disease respective team for peri-operative antiplatelet management 1 See Appendix A for Procedural Bleeding Risks based on type of procedure ● For management of other agents, see Appendix D 2 If patient on monotherapy with a P2Y12 inhibitor for secondary prevention or history of coronary/intracranial/ ● For patients undergoing carotid stent placement and on aspirin and/or P2Y12 inhibitor, do carotid stent > 1 year ago, consider holding P2Y12 inhibitor as recommended (see Appendix D) and not hold antiplatelet therapy prior to procedure initiating aspirin while the P2Y12 inhibitor is on hold. If needed, consult appropriate service depending on indication for P2Y12 inhibitor prior to holding. Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 06/15/2021 Peri-Procedure Management of Antiplatelet Therapy Page 4 of 17 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. APPENDIX A: Procedure Bleeding Risk Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures. High Bleeding Risk Moderate Bleeding Risk Low Bleeding Risk General Procedures ● Regional anesthesia (neuraxial and deep peripheral nerve ● Bone marrow aspiration and biopsy ● Ommaya reservoir puncture procedures) including lumbar puncture (see Appendix C) ● Venous port placement Breast Surgical and Breast Radiology Procedures ● All OR Breast Surgical procedures ● Biopsy and fine needle aspiration of breast, axillary nodal ● Breast punch biopsy in clinic basins, internal mammary, and/or supraclavicular lymph nodes ● Image guided pre-operative localization of the breast Cardiology Procedures ● Coronary intervention ● Diagnostic coronary angiography via femoral access ● Arterioventricular node ablation ● Endomyocardial biopsy ● Electrophysiology testing and/or ablation ● Coronary artery angiography (radial approach) ● Implantable cardioverter-defibrillator/pacemaker lead ● Pacemaker or defibrillator placement ● Internal cardiac defibrillator implantation battery change extraction ● Right heart catheterization ● Permanent pacemaker implantation battery change ● Left atrial appendage occlusion device ● Supraventricular tachycardia