- Recommendation ID
What is the most clinical and cost-effective strategy, as identified by a consensus survey, for the perioperative management of anticoagulation treatment in people taking a vitamin K antagonist with a target international normalised ratio (INR) of more than 3 who need bridging therapy?
- Any explanatory notes
Why the committee made the recommendations
Assessing the risks of surgery
Validated preoperative risk stratification tools are freely available and can be completed rapidly. Although no risk stratification tool is 100% accurate, the evidence showed that validated tools are sufficiently accurate to be a useful supplement to clinical assessment.
The committee noted that a validated risk stratification tool can also help to frame discussions about risk with the person having surgery. This includes changes the person can make to reduce their risk, such as stopping smoking. The committee agreed that the risk of postoperative morbidity is an important concern for people when they are making decisions about surgery.
Preoperative optimisation clinics for older people
Preoperative optimisation clinics for older people are designed to reduce complications and deaths associated with surgery by proactively addressing risk factors identified during the preoperative assessment. These clinics are not available in all areas and are expensive to establish. Although a small number of studies suggested a possible improvement in surgical outcomes, the evidence was inconclusive. The committee decided that, because of the high cost and lack of clear evidence, they could not make a recommendation on these clinics. However, they agreed that this is an important area and made a recommendation for research on preoperative optimisation clinics for older people.
Oral iron regimens
Oral iron supplements are usually taken daily but some people have unpleasant side effects from daily iron. The committee thought that, for these people, switching to an alternate-day regimen should be considered as a means of reducing side effects and encouraging adherence. They noted that an alternate-day regimen does not address problems with tolerability or absorption, and the potential benefits need to be balanced against the risk that an alternate-day regimen might be more complicated for people taking multiple daily medicines. There was no evidence on the comparative effectiveness of daily and alternate-day oral iron regimens.
When to start oral iron supplementation
In all of the studies, iron supplementation had been started about 3 weeks before surgery. In current practice, this varies. There were no studies that compared different starting times so the committee were unable to determine the best time to start iron therapy before surgery.
The committee made a recommendation for research on oral iron supplementation.
Anticoagulation for people taking a vitamin K antagonist who need bridging therapy
People who take a vitamin K antagonist are at high risk of venous thromboembolism or stroke and therefore, it is usual practice to provide bridging anticoagulation during surgery with either subcutaneous low molecular weight heparin (LMWH) or intravenous unfractionated heparin (UFH). No clinical evidence was identified comparing LMWH with UFH in this high-risk group of patients. The committee noted that people who take a vitamin K antagonist with a target international normalised ratio (INR) of more than 3 and who need bridging therapy are a small proportion of the population taking vitamin K antagonists, and that many of these people have mechanical heart valves. Because of the lack of evidence, the committee made a recommendation for research on managing anticoagulation treatment for people taking a vitamin K antagonist who need bridging therapy.
No evidence on nutritional assessment was available. The committee noted that nutritional deficiency contributes to reduced physiological resilience, which is associated with increased complications and perioperative mortality. Because of this, they agreed that preoperative nutritional screening is useful for people having intermediate, major or complex surgery.
How the recommendations might affect practice
Assessing the risks of surgery
Preoperative risk stratification tools are commonly used in current practice and the recommendation is not expected to change practice.
Oral iron regimens
The option to consider switching from a daily to an alternate-day regimen might increase adherence to oral iron therapy in people who have unpleasant side effects from daily iron. This has the potential to reduce the need for blood transfusions and improve surgical outcomes for this group of people.
Preoperative nutritional assessment for intermediate, major or complex surgery is current practice and the recommendation is not expected to lead to changes in practice.
Source guidance details
- Comes from guidance
- Perioperative care in adults
- Date issued
- August 2020
|Is this a recommendation for the use of a technology only in the context of research?||No|
|Is it a recommendation that suggests collection of data or the establishment of a register?||No|