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Assoc iate Prof Tatjana Šimurina MD, PhD

8 th Croatian-European-American A nesthesiology Conference , HDARIM, May 23-26, 2019. Plitvice Lakes , Croatia. Antithrombotic therapy in outpatients undergoing eye surgery under regional anesthesia - new approaches. Assoc iate Prof Tatjana Šimurina MD, PhD

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Assoc iate Prof Tatjana Šimurina MD, PhD

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  1. 8th Croatian-European-American AnesthesiologyConference, HDARIM, May 23-26, 2019. Plitvice Lakes, Croatia Antithrombotic therapy in outpatients undergoing eye surgery under regional anesthesia - new approaches AssociateProf Tatjana Šimurina MD, PhD General Hospital Zadar; Dept.of Health Study, University of Zadar; Assist Prof - Medical faculty, University of Osijek tsimurina@unizd.hrtatjana.simurina@mefos.hr

  2. Conflictofinterests None Old postcard: “ A blind man from Kotari”, Dalmatia, Croatia

  3. outline • thromboticriskrelated to modificationofantithrombotictherapybeforeeye-surgery • riskofintraoperativeandpostoperativebleedingassociatedwithcontinuationofantithrombotictherapy • approach to ophthalmicpatientson preoperativeantithrombotictreatment

  4. Introduction • Continuous trend of increased eyesurgery • patientcharacteristics • Elderly • Co-morbidities • Takingmedications • Antithromboticagents (anticoagulants / antiplatelets , ac/Ap) : >28% aspirin, 2% clopidogrel; >5% anticoagulants • Increasingtendencytowardregionalanesthesia (>95%) for eyesurgery • orbital NEEDLE blocks: retrobulbar (intraconal), peribulbar(Extraconal) • cannulablock (episcleralsubtenon‘s) • subconjunctivalortopical (intracameral) anesthesia • Guidelines: • https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2012-sci-247-local-anaesthesia-in-ophthalmic-surgery-2012.pdf • https://www.rcoa.ac.uk/system/files/gpas-2019-13-ophthal.pdf • https://rapm.bmj.com/content/rapm/43/3/263.full.pdf HorlockerTT etal. RegAnesthPain Med 2018;43:263–309

  5. Expansion of ophthalmic ambulatory anesthesia (AA) • Contributing factors to the growth of ophthalmic AA • minimally invasive eye-surgical techniques • improvements in anesthesia techniques and pain control • characteristics of ophthalmic patient population • economic pressures With permission from WMG Health

  6. Commonday-caseeyesurgeries • Cataractextraction • Strabismusrepair • Glaucomasurgery • Nasolacrimalductprobing • Chalazionexcision • Eyeexamination(tonometry) • Longer eyesurgery + high risk of perioperative complications - not appropriate for Ambulatoryanesthesia • Eye surgery – low risk (cardiac risk <1%)* *DeHertS, ImbergerG, CarlisleJ, etal. EurJ Anaesthesiol 2011;28:684-722

  7. Indications for antithrombotictherapy • Strokepreventioninatrialfibrillation (AF) • The management andpreventionofthromboembolism • Mechanicalheartvalve (MHV) • Treatmentofacutecoronarysyndrome • Secondarypreventionofcardiovasculardisease

  8. Risk of hemorrhagic complications • High - orbital and major oculoplasticsurgeries • Intermediate- vitreoretinal, glaucoma, corneal transplant • Low - cataract surgery, intravitreal injections • Surgical bleeding and needle block hemorrhageCAN be detrimental for visual function (limitedsurgicalfieldinocularsurgery) • High/ intermediate risk surgery + needleblockin a patient with ap/ac therapy - not appropriate for outpatient setting • no evidence of increased bleeding risk in peribulbar/retrobulbaranesthesia • single shot inferonasalpuncture/ narrow, short needle/ smallincision

  9. riskstratification for bleedinginneedleandcannulablocks Kiire CA et al. Br J Ophthalmol 2014;98:1320-4. 

  10. Theriskofintra/postoperativehemorrhage • Older age • LIVER/ renalFAILURE, ANEMIA, DIABETES • UNCONTROLLED HYPERTENSION; ATHEROSCLEROSIS; CARDIAC STENT • family History of (H/o) bleeding or clotting disorders • H/othromboembolicevents • Antithrombotics, Steroidsandherbaltreatment • Eyefeatures: choroidalsclerosis, glaucoma, myopiceye • Typeofeyesurgery • recenteyesurgery

  11. risk stratification for bleeding ineyesurgery Kiire CA et al. Br J Ophthalmol 2014;98:1320-4

  12. To stop Ap/Acorcontinue ? Riskoflife-threateningthromboemboliceventswhilediscontinuedormodifiedAp/Ac therapy Riskofsurgicalbleedingandvision –threateninghemorrhageifAp/Ac continued For most ophthalmic operationsthe risk of stopping antithrombotic therapy is higher than the riskof continuingantithrombotics. .

  13. DouketisJD et al. Perioperative Bridging Anticoagulation in Patients with AtrialFibrillation.N Engl J Med 2015;373(9):823–33. To bridge or not to bridge ? • TheBRIDGE trial, randomized, double-blind, placebo-controlled N=1884 (2009- 2014), AF, warfarintherapy, surgery: gastrointestinal, cardiothoracic, orthopedic *P for noninferiority † P for superiority

  14. doesmyophthalmicpatientneedbridgingtherapy? Clinicalscenario • A 60-year-old manwithnormalrenalfunctionhasbeentaking NOAC dabigatran for preventionofstrokeinnon-valvularatrialfibrillation. He wasscheduled to havecombinedphacoemulsificationwithtrabeculectomyinambulatorysettingunderintraconal/extraconalblock. • highbleedingriskwaspresumedandNoacwasstopped 48 hoursbefore procedure andresumed 24 hoursaftercompletehemostasis.

  15. Keys to success • Individualizedapproach • AntithromboticS (noveldrugs) • typeofanesthesia • Typeofeye-surgery • renalfunction • Multimodalapproach • consultation • Communication

  16. Antiplatelettherapyineyesurgery Bonhomme F. etal. Eur J Anaesthesiolo 2013; 30:449-54

  17. AntiCoagulanttherapyineyesurgery Bonhomme F. etal. Eur J Anaesthesiolo 2013; 30:449-54

  18. DirECT ORAL antiCoagulanTS IN EYE SURGERY Bonhomme F. etal. Eur J Anaesthesiolo 2013; 30:449-54

  19. UyhaziKE et al. association of novel oral antithrombotics with the risk of intraocular bleeding.JAMA Ophthalmol2018;136:122-30. • Retrospectivecohortstudy, nationalinsuranceclaimsdatabasefrom 2010-2015; Mainoutcome: hazard ratio (HR) ofdevelopingintraocularhemorrhage at 90 and 365 days, 2 parallelanalyses: • Dabigatranorrivaroxabanvs WarfarinPrasugrelvs Clopidogrel

  20. ConclusionS • Regional anesthesia can safely be applied to most outpatientseyesurgeryprocedureswith continued antithrombotic therapy • Modification of perioperative antithrombotic therapy in ophthalmic patients requires a multidisciplinary approach • Anesthesiologist has a leading role in preventing and resolving complications inophthalmicregionalanesthesia • ʺone size fits all approach” is not advisable for ophthalmic patients on Ap/Actherapy and individualized approach is recommended • localprotocols to minimizeantithromboticdiscontinuationandthromboticevents, are highlyrecommended

  21. T 60 H A N 50 k s fo r 40 A TTENTi 30 ondoy ouHAv 20 E anYQu E s tio N s 10

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