PIG Meeting: 22nd April 2021
71-year-old man for titanium cranioplasty following a traumatic subdural haematoma.
- Recent long and complicated hospital stay
- Iatrogenic bowel perforation leading to septic shock requiring ICU and vasopressors
- Developed ischaemic limb on background of previous vascular stents and SLE
- Had been on lifelong warfarin and Plavix.
- Restarted on warfarin and aspirin on pre-discharge
- Hit head in rehab, traumatic subdural requiring emergency craniectomy and a further ICU admission
- Currently home, back on warfarin and aspirin
- History of SLE with high titre of anticardiolipin antibodies.
- Distance patient
- Neurosurgical team requiring cessation of anticoagulation and antiplatelet therapy
- Patient and wife very worried about cessation of anticoagulation then travel to hospital.
- Patient states leg is still ‘dusky’
1. How to best manage anticoagulation
- Multiple competing interests
- Vascular team happy for warfarin to be ceased from a stent perspective
- Immunologist concerned regarding high thrombosis risk and advised shortest possible interruption of therapy.
- Recommends patient should have a high INR target of 2.5-3.5 and should receive enoxaparin or heparin anticoagulation as per high-risk protocol
- Haematologist agrees with immunologist and will consult as an inpatient.
2. Heparin vs Enoxaparin
- Heparin may be preferable as will be inpatient
- Neurosurgeon keen to cease warfarin 5 days preoperatively
- Suggestion to keep warfarin going until admitted then reverse warfarin and commence heparin infusion
- Good plan but dependent on bed availability, Enoxaparin can be given regardless
- Cease warfarin 5 days preoperatively.
- Commence 1.5mg/kg Enoxaparin 1 day after ceasing warfarin
- Admit to hospital 2 days preoperatively
- Haematologist review as inpatient
- Last dose Enoxaparin 24 hours preoperatively