PIG Meeting: 22nd April 2021

71-year-old man for titanium cranioplasty following a traumatic subdural haematoma.

Background:

• 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

Issues

• 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’

Discussion

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

Plan:

• 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