Management strategies in patients with high bleeding and clotting risk

Abstract

Patients undergoing major orthopaedic surgery are at high risk of venous thromboembolism (VTE), with morbid and potentially fatal consequences. Anticoagulant VTE prophylaxis reduces rates of postoperative deep vein thrombosis by up to 60-70% in these patients. Therefore, pharmacological prophylaxis with low-molecular-weight heparins (LMWHs), vitamin K antagonists, or fondaparinux and now new oral anticoagulants, is recommended by current guidelines. However, there remains an ongoing debate regarding when to initiate prophylaxis, and the optimal duration for prophylaxis. The benefit-to-risk ratio associated with pre- and postoperative initiation of thromboprophylaxis in cases of neuraxial anaesthesia has to be debated. As the main route of elimination for many anticoagulants is via the kidney, some patients with impaired renal function receiving thromboprophylaxis may experience increased surgical bleeding, which may have a detrimental effect on clinical and functional outcome. Age also influences bleeding risk. Older patients have more co-morbidities and an increased risk of venous and arterial thromboembolic complications and death compared with younger patients. At the same time, there is an inverse relationship between renal function and age. Therefore, an appropriate antihaemostatic dosing regimen appears to be particularly pertinent for these patients. Providing optimal thromboprophylaxis throughout the critical thrombosis period where a patient is at risk for VTE will ensure the best possible reductions in VTE related morbidity and mortality.