SLE and PVD for Neurosurgery

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

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