Preoperative Patients on Coumadin

If you work in surgery or with the elderly - anticoagulation is an every day part of life. INRs, PTs, PTTs, etc... it is important to know what measures what and what reversal agents (if any) are available. Let's talk about Coumadin today.

Scenario: 79 yo patient is coming in for a surgical procedure, but he is on Coumadin. You did your due diligence and had them stop it about 5 days pre-op, but their INR is still 1.6 on preoperative blood work. What are your next steps?

Generally if you are going to bring someone to the OR you'd like their INR to be less than 1.5. If it is higher, you would consider a reversal agent.

Your 1st option for reversal is Vit K
  • PO is most predictable and is preferred to IV if rapid reversal is not needed. PO Vit K lowers INR in about 24-48 hours. 
  • IV works in approximately 12-24 hrs, but you run a greater risk of anaphylaxis and it must be administered over a longer period of time (approx 20 minutes). 
Your 2nd option for reversal is Fresh Frozen Plasma (FFP).
  • FFP is more expensive than Vit K, but works within 12 hrs. FFP replaces clotting factors.
So, even though you did your due diligence, why was the INR still high? There are several reasons that can delay the drop of a patient's INR:
  1. Age - Elderly pts
  2. Malignancy (active)
  3. Liver disease
  4. CHF, unstable
  5. Meds that keep Coumadin around in the blood (check their med list)

Ansell, J, Hirsh, J, Poller, L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:204S. 

Normalization of INR After Stopping Coumadin: http://www.fpnotebook.com/mobile/HemeOnc/Surgery/PrprtvAntcgltn.htm


Surgical Training for Neurosurgical PAs

Last week I had the privilege of attending a surgical training in San Francisco, California. The event was created by the Association of Neurosurgical Physician Assistants (ANSPA) in conjunction with Ethicon. I must say it was a fantastic experience. I was able to spend a half a day in a live porcine wet lab. The lab was for PAs only so it enabled me to spend more time with the surgical instruments and take the lead on certain aspects of the surgeries that we performed - both opportunities that I don't necessarily get on a day to day basis. It was successful in building my confidence.

We performed a craniotomy and tumor removal as well as a laminectomy with a focus on hemostasis. This is an unusual experience and I learned a great deal from both the PAs that attended and the Ethicon reps regarding hemostasis products. I had the least amount of surgical experience of all the PAs that were there (9 months), however all of the PAs were friendly and helpful and I learned quite a few new techniques. It was also inspirational to see what other PAs around the nation were doing as part of their daily grind. It ranged from PAs that spent the majority of their time in the OR as co-surgeons to those that split their time 50-50 between OR and floor work.

I was able to meet and spend some time with Josh, a neurosurgical PA for over 10 years, who is the current president of ANSPA. The AAPA recently completed a video on him and his contributions to his neurosurgical practice. The surgeons that he works with on a daily basis speak very highly of his surgical and patient skill sets. Mike Nido, PA-C and Dean Barone, PA-C were also instrumental in making this event happen.

All in all, hats off to ANSPA for working hard to make this happen for PAs. They hope to create more of these learning opportunities for neurosurgical PAs in the near future. If you are not a member, I highly encourage you to do so if you're interested in neurosurgery as a physician assistant.

*Disclosure: I am in no way financial tied to Ethicon. Just attended the event.