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Improving Approaches to Perioperative Care
We as podiatric surgeons mustconsider several things when planning to take a patient to surgery. Generally, the forefront of our thoughts includes what surgery we are doing, necessary hardware, postop assistive devices, and scheduling elements. For some patients, we must take certain medical preoperative considerations into account, such as with patients with diabetes, coagulopathies, seronegative arthropathies, a recent history of cardiac events or interventions, or mental health conditions that may impact recovery from surgery. We often collaborate with primary care physicians, rheumatologists, pharmacists, anesthesiologists, and endocrinologists to help manage these patients. However, we should also deeply and independently understand what these patients need medically prior to and on the day of surgery to help achieve successful outcomes. As there are multiple perioperative considerations one could discuss, this article will focus only on perioperative management of patients receiving anticoagulants and patients with rheumatoid arthritis. This article will predominately focus on elective surgeries rather than urgent or emergent cases.
Important Perioperative Insights for Patients on Anticoagulant Therapy
When planning to perform surgery on a patient currently on an anticoagulant, several considerations come into play. Taking the patient off the anticoagulant prior to surgery places them at risk for a thromboembolic event, while leaving them on their medication throughout the perioperative period increases their risk of a bleeding event. One must balance both of these risks and consider the urgency of the planned podiatric surgery.
As we seek to minimize adverse events, we need to evaluate two major items: the bleeding risk of the surgery and the patient’s thromboembolic risk. Patients fall into either high, moderate, or low thrombotic risk categories, based on the indication for anticoagulant therapy and their CHA2DS2-VASc score (see table below).1 The highest risk is atrial fibrillation, prosthetic heart valves, and recent venous or arterial thromboembolic events. For patients with atrial fibrillation, a CHA2DS2-VASc score of 0 to 3 is considered low risk, a score of 4 to 6 is moderate risk, and a score of 7 to 9 correlates to a high risk of a thrombotic event.2 For previous venous thrombotic events (VTE), risk is based on the timing of the last event. Greater than 12 months is low risk, 12 months prior is moderate risk and within 3 months places them in the high-risk category.2 For heart valve patients, bileaflet aortic valve prosthesis without other risk factors is low risk, bileaflet aortic valve with 1 risk factor is moderate risk, and any mitral valve prosthesis, stroke or transient ischemic attack (TIA) within the past 6 months places the patient in a high-risk category.2 Recommendations include not proceeding with elective surgery on patients in the high-risk category.2
Bleeding risk assessment is the next major step to successfully treating these patients. Overall, patients split into two categories, high and low bleeding risk.3 High bleeding risk indicates a patient has a postoperative two-day risk of a major bleed between 2 and 4 percent. Those with low bleeding risk have a 0 to 2 percent risk of a postoperative two-day major bleed. For podiatric surgeons, most of our cases would fall into the high-risk category as foot surgery and a major operation of duration greater than 45 minutes both fall in this category. Surgeries such as arthroscopic surgery lasting less than 45 minutes and cutaneous surgeries fall into the low bleeding risk category.3
Understanding the Details of Discontinuing Anticoagulants
Once one establishes the bleed risk and thromboembolic risk for a patient, we can begin to evaluate if and when to discontinue anticoagulants. In general, if the surgical bleed risk is high, anticoagulants warrant discontinuation, possibly with bridging in certain circumstances. In low bleed risk surgeries, anticoagulants need not be discontinued.3
As most podiatric surgeries fall into the high-risk bleed category, we need to understand how long to discontinue anticoagulants before and after surgery. Anticoagulants fall into two major categories, vitamin K antagonists (warfarin) and direct oral anticoagulants. Direct oral anticoagulants include argatroban (Acova), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Lixiana).2 Oral anticoagulants are the most common ones we will encounter in elective surgery, but we also need to be aware of any injectable anticoagulants like enoxaparin sodium (Lovenox) or heparin and adjust them as necessary. For the purpose of this article we will focus on oral anticoagulants.
The PAUSE (Perioperative Anticoagulation Use for Surgery Evaluation) study4 gives us a protocol for the timing and discontinuance of direct oral anticoagulants. This study states that patients who take direct oral anticoagulants, have normal kidney function, and are undergoing high bleed risk surgery, should discontinue anticoagulants 2 days prior to surgery and then restart 48 hours after surgery.4 Overall, patients will not take their anticoagulant for 4 days. A low bleeding risk procedure will then warrant patients discontinuing their anticoagulant 1 day prior to the surgery, restarting 24 hours after the surgery for a total of 2 days of not taking their direct oral anticoagulant (see figure below). With these direct oral anticoagulants, bridging is unnecessary due to their rapid offset and onset.5
When patients take warfarin they should discontinue it 5 days prior to surgery. This is different than direct oral anticoagulants due its longer half-life. The patient then restarts the warfarin 12 to 24 hours after the surgery. Warfarin, unlike direct oral anticoagulants, needs to have INR checked the day prior to surgery, with a value less than 1.5 necessary in order to proceed.6 If too high, then one may consider low dose oral vitamin K administration.6 Many of us learned in school and residency that bridging with heparin was always necessary when discontinuing warfarin prior to surgery. More and more recent evidence6-12 shows that, in a majority of people, bridging does not reduce the risk of thromboembolic events, but does increase postoperative bleeding. Thus, current recommendations only support bridging in patients who fall into the high-risk category. This would include patients with mechanical valves, with additional stroke risks, those with strokes or a VTE in the past three months, and patients with a CHA2DS2-VASc score of 7 to 9. In the realm of podiatric surgery, most of these high-risk individuals are not ideal candidates for elective surgery, thus those that we take to surgery generally do not need bridging, even if they are on warfarin.
Reversal agents may come into play in emergency surgery cases. Fresh frozen plasma along with vitamin K can immediately reverse warfarin. Dabigatran can be reversed by idarucizumab while andexanet alfa reverses rivaroxaban, apixaban and edoxaban.13-15 These agents carry a high risk of life-threatening thrombosis and thus are only for patients at imminent risk of bleeding to death. We as podiatrists alone would not administer these agents.
Overall, key points to remember when dealing with patients on anticoagulants needing elective surgery; direct oral anticoagulants, discontinue 2 days prior to surgery and restart 48 hours after surgery with no bridging needed. With warfarin, discontinue 5 days prior to surgery and restart 12-24 hours after surgery with no bridging needed, those with a recent thromboembolic event should have elective surgery delayed.
Pertinent Perioperative Considerations for Patients With Rheumatoid Arthritis
Another very common patient population that podiatrists take to surgery is those with rheumatoid arthritis. Many times these patients require a team approach to make sure we reduce their risk of postoperative complications, including their rheumatologist, the anesthesia team, cardiology and the patient’s primary care provider. Our patients should work with their rheumatologist to control their disease state and optimize medications prior to proceeding with elective surgery. One major risk factor for mortality in patients with rheumatoid arthritis is cardiovascular disease. Patients with rheumatoid arthritis experience a 48 percent increase in cardiovascular events and surgery can further increase this risk.16 Having these patients undergo a stress test or obtaining clearance from their primary care provider or cardiologist can assure that they are healthy enough to undergo surgery.
Glucocorticoids are another major consideration for those undergoing elective surgery. Not only does chronic steroid use increase risk of postop infections (as high as 20 fold in patients taking 15mg of prednisone daily),17 but they can also lead to hemodynamic instability due to glucocorticoid-induced adrenal insufficiency. If a patient takes over 10mg of prednisone daily, it is likely wise to postpone surgery until disease activity is more controlled.17 For those with adrenal insufficiency, a 100mg IV dose of hydrocortisone should given by the anesthesia team at induction and then 200mg IV given daily afterwards until they are able to tolerate oral medications. Once the patient transitions to oral medications, the dose is tapered down to their original maintenance dose with the goal of returning to that maintence dose within 48 hours after surgery.18
Besides glucocorticoids, other medications that these patients take that are of significant concern in the perioperative setting are the nonbiological disease modifying anti-rheumatic drugs (DMARDS) and biologic DMARDS. The nonbiologics include medications such as methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine. Biologic DMARDs include infliximab, adalimumab, etanercept, rituximab, abatacept, rituximab, tocilizumab, and tofacitinib.19 There is a concern that these medications will increase the risk of postop infections as well as wound dehiscence, and thus warrant discontinuation during the perioperative period. This risk has not yet borne out in the literature.
Loza and team stated that “continuing with low doses of MTX seems to be a safe option during the perioperative period in rheumatoid arthritis patients without relevant comorbidities and/or risk factors of infections, undergoing elective orthopedic surgery, while maintaining disease control.”19 Escalante and colleagues were unable to demonstrate an independent effect of antirheumatic therapy at the time of surgery on the occurrence of postoperative wound complications.20 Thus, current recommendations suggest that it is not necessary to discontinue nonbiologic DMARDs prior to and immediately after surgery.21
One the other hand, recommendations for biologic DMARDs do include holding these medications prior to surgery and until the wound heals, largely based on indirect evidence suggesting an increased risk of infection.21 There is limited data that supports the infection risk being similar across all biologics. The schedule to take patients off of these medications depends on the dosing schedule itself. One should schedule the surgery in question at the end of the medication dosing cycle. For example, for medications dosed weekly, the patient skips the/first dose and then surgery takes place in the second week (7 to 14 days) after the skipped dose. For those medications dosed monthly, the patient skips the first dose and surgery takes place in the fifth week. The medications can then resume once the wound has healed. When the patients are off their biologic DMARDS, their pain will increase due to underlying disease not being treated and they, as well as we, should prepare for this.21
Another risk factor to consider is that patients with inflammatory diseases, such as rheumatoid arthritis, are at higher risk for VTEs, including deep venous thrombosis and pulmonary embolism.22 The literature has not showed a higher risk of VTE for patients with rheumatoid arthritis having outpatient orthopedic surgeries, but there is an increased risk for those patients that need hospitalization after surgery.22 This risk increases even more for those with concomitant antiphospholipid syndrome.22 There should be a plan in place perioperatively for patients with antiphospholipid syndrome that will decrease the patient’s risk of thrombosis by minimizing time spent off anticoagulation while simultaneously not increasing bleeding risk.
The final major risk factor for the patient with rheumatoid arthritis undergoing surgery relates to disease within the cervical spine, specifically an increased risk of atlantoaxial subluxation.23 This can pose many challenges to intubation for our anesthesia colleagues. Preoperative radiographic cervical spine views are generally necessary to help evaluate for any issues prior to surgery.
Concluding Thoughts
Although there are many perioperative medical considerations that we as podiatric surgeons need to be aware of, this article focused on two of the more common ones; patients on anticoagulants and those with rheumatoid arthritis. Although awareness of risks and recommendations is paramount, we should work as a multidisciplinary team to help our patients have a safe and successful surgery.
Dr. Jones is the Chairman and a Fellow of the American Society of Podiatric Surgeons, as well as a Fellow of the American College of Podiatric Medicine. He practices in Spokane, WA.
This article was created in partnership with the American Society of Podiatric Surgeons.
References
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