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Thoracic Surgery

Summary: Perioperative Management of Patients Taking Direct Oral Anticoagulants

19 Sep, 2024 | 21:12h | UTC

Direct oral anticoagulants (DOACs)—including apixaban, rivaroxaban, edoxaban, and dabigatran—are increasingly used for stroke prevention in atrial fibrillation and for treating venous thromboembolism. Effective perioperative management of DOACs is essential to minimize bleeding and thromboembolic risks during surgical and nonsurgical procedures. Below are practical recommendations focused on the perioperative management of patients taking DOACs, based on a recent JAMA review article.

Elective Surgical or Nonsurgical Procedures

Classify Bleeding Risk of Procedures:

  1. Minimal Risk:
    • Minor dental procedures (e.g., cleaning, extractions)
    • Minor dermatologic procedures (e.g., skin lesion removal)
    • Cataract surgery
  2. Low to Moderate Risk:
    • Endoscopic procedures without high-risk interventions
    • Cholecystectomy
    • Inguinal hernia repair
  3. High Risk:
    • Major surgery (e.g., cancer surgery, joint replacement)
    • Procedures involving neuraxial anesthesia
    • Endoscopic procedures with high-risk interventions (e.g., large polyp removal)

DOAC Management Strategies:

  1. Minimal Bleeding Risk Procedures:
    • Option 1: Continue DOACs without interruption.
    • Option 2: For added safety, withhold the morning dose on the day of the procedure (especially for twice-daily DOACs like apixaban and dabigatran).
  2. Low to Moderate Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 1 day before the procedure.
      • This allows approximately 2 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 1 day after the procedure, ensuring adequate hemostasis.
  3. High Bleeding Risk Procedures:
    • Preoperative:
      • Discontinue DOACs 2 days before the procedure.
      • This allows approximately 4-5 half-lives for drug clearance.
    • Postoperative:
      • Resume DOACs 2-3 days after the procedure, based on bleeding risk and hemostasis.

Evidence Supporting These Strategies:

  • The PAUSE study demonstrated that standardized interruption protocols without heparin bridging result in low rates of:
    • Thromboembolism: 0.2%–0.4%
    • Major Bleeding: 1%–2%

Postoperative DOAC Resumption:

  • Assess surgical-site hemostasis before resuming DOACs.
  • Delay resumption if there is ongoing bleeding or concerns about hemostasis.
  • For high bleeding risk procedures, consider a longer delay (2–3 days).

Perioperative Heparin Bridging:

  • Not recommended for patients on DOACs.
  • Bridging increases bleeding risk without reducing thromboembolism.
  • DOACs have rapid offset and onset, making bridging unnecessary.

Special Considerations

Patients with Impaired Renal Function:

  • For CrCl 30–50 mL/min:
    • Dabigatran: Extend preoperative discontinuation by an additional day.
  • For CrCl <30 mL/min:
    • Dabigatran is contraindicated.
    • For other DOACs, consider extending discontinuation to 3–4 days before surgery.

Patients Undergoing Neuraxial Anesthesia:

  • Discontinue DOACs for 3 days (apixaban, edoxaban, rivaroxaban) or 4 days (dabigatran) before the procedure.
  • Minimizes risk of spinal or epidural hematoma.

Dental Procedures:

  • Generally safe to continue DOACs.
  • For added safety:
    • Omit or delay the dose on the day of the procedure.
    • Employ local hemostatic measures (e.g., tranexamic acid mouthwash).

Endoscopic Procedures:

  • Low-risk procedures (e.g., diagnostic endoscopy without biopsy):
    • Follow standard DOAC interruption for low to moderate bleeding risk.
  • High-risk procedures (e.g., polypectomy of large polyps):
    • Extend DOAC discontinuation by an additional day pre- and post-procedure.

Patients Unable to Resume Oral Medications Postoperatively:

  • Use prophylactic low-molecular-weight heparin (LMWH) until oral intake is possible.
  • Avoid therapeutic-dose LMWH due to bleeding risk.

Emergent, Urgent, or Semiurgent Procedures

Risks:

  • Higher bleeding risk: Up to 23%
  • Thromboembolism risk: Up to 11%

Management Strategies:

  1. Assess Time Since Last DOAC Dose:
    • If within 48 hours, consider that significant anticoagulant effect may persist.
  2. Laboratory Testing (if available):
    • DOAC Level Testing:
      • ≥50 ng/mL: Consider using reversal agents.
      • <50 ng/mL: May proceed without reversal agents.
  3. Use of Reversal Agents:
    • For Dabigatran:
      • Idarucizumab (5 g IV)
    • For Factor Xa Inhibitors (apixaban, rivaroxaban, edoxaban):
      • Andexanet alfa (dosing based on last dose timing and amount)
      • Prothrombin Complex Concentrates (PCCs): If andexanet alfa is unavailable or contraindicated.
  4. Proceeding Without Testing:
    • If testing is unavailable and last DOAC dose was within 48 hours, consider reversal agents.
    • If >48 hours since last dose, may proceed without reversal.

Considerations:

  • Reversal agents are expensive and may carry thrombotic risks.
  • Use should be judicious, weighing risks and benefits.
  • Consult hematology or thrombosis experts when possible.

Key Takeaways

  • Elective Procedures:
    • Utilize standardized protocols based on procedural bleeding risk.
    • Routine preoperative DOAC level testing is unnecessary.
    • Avoid heparin bridging.
  • Emergent/Urgent Procedures:
    • Reversal agents may be appropriate when significant DOAC levels are present.
    • Decision to use reversal agents should consider bleeding risk, time since last dose, and availability of DOAC level testing.
  • Patient Communication:
    • Ensure patients understand the plan for DOAC interruption and resumption.
    • Provide clear instructions regarding timing and dosing.
  • Interdisciplinary Coordination:
    • Collaborate with surgical teams, anesthesiologists, and pharmacists.
    • Use electronic medical records and clinical decision support tools to enhance communication.

Conclusion

By applying standardized perioperative management protocols, clinicians can effectively balance the risks of bleeding and thromboembolism in patients taking DOACs who require surgical or nonsurgical procedures. These strategies simplify decision-making, avoid unnecessary interventions like heparin bridging, and promote patient safety.

Reference: Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA. 2024;332(10):825–834. doi:10.1001/jama.2024.12708

 

Retrospective Cohort Study: Rheumatoid Arthritis Linked to Over 50% Increased Lung Cancer Risk, with a Three-Fold Risk in RA-Associated Interstitial Lung Disease – Arthritis Rheumatol

18 Aug, 2024 | 18:58h | UTC

Study Design and Population: This retrospective matched cohort study examined the risk of lung cancer in 72,795 patients with rheumatoid arthritis (RA) and 757 patients with RA-associated interstitial lung disease (RA-ILD) from the Veterans Health Administration database, compared with 633,937 non-RA controls. The study spanned from 2000 to 2019, with patients matched on age, gender, and enrollment year.

Main Findings: The study found that RA was associated with a 58% increase in lung cancer risk (adjusted hazard ratio [aHR] 1.58). The risk was significantly higher in RA-ILD patients, with a more than three-fold increase (aHR 3.25) compared to non-RA controls. Even among never smokers, RA patients showed a 65% increased lung cancer risk, indicating that factors beyond smoking contribute to the elevated risk.

Implications for Practice: The study underscores the significant increase in lung cancer risk among patients with RA, particularly those with RA-ILD. While this elevated risk is notable, further research is necessary to determine the most effective strategies for monitoring and managing this risk. Clinicians should be aware of these findings and consider them when evaluating the overall health and risk factors of patients with RA, especially those with additional pulmonary complications like ILD. Enhanced awareness and individualized risk assessments may help in early detection and management of lung cancer in this high-risk population.

Reference: Brooks RT, Luedders B, Wheeler A, et al. (2024). The Risk of Lung Cancer in Rheumatoid Arthritis and Rheumatoid Arthritis–Associated Interstitial Lung Disease. Arthritis & Rheumatology, 0(0), 1-9. DOI: 10.1002/art.42961.

 

Study Shows High Prevalence of Solid Lung Nodules in Nonsmoking Adults – Radiology

14 Aug, 2024 | 13:14h | UTC

Study Design and Population: This cohort study examined the prevalence and size distribution of solid lung nodules in a nonsmoking population from the Northern Netherlands. A total of 10,431 participants aged 45 years and older, predominantly nonsmokers, were included in the Imaging in Lifelines (ImaLife) study. The study utilized low-dose chest CT scans to detect and measure lung nodules.

Main Findings: Lung nodules were present in 42% of participants, with a higher prevalence in males (47.5%) than females (37.7%). The prevalence of clinically relevant nodules (≥100 mm³) was 11.1%, and actionable nodules (≥300 mm³) were found in 2.3% of individuals. Both prevalence and nodule size increased with age, and male participants consistently showed a higher prevalence and larger nodule sizes compared to females.

Implications for Practice: While 42% of nonsmoking adults in this Northern European cohort were found to have solid lung nodules, the incidence of lung cancer within this population is notably low. This suggests that many of the clinically relevant and even actionable nodules identified in nonsmokers are likely benign. These findings highlight the need to refine nodule management strategies for individuals at low risk of lung cancer, potentially reducing unnecessary follow-up and interventions in nonsmoking populations. Future research on lung cancer outcomes in this cohort could further inform and optimize guidelines for nodule management in low-risk groups.

Reference: Cai, J., Vonder, M., Pelgrim, G. J., Rook, M., Kramer, G., Groen, H. J. M., de Bock, G. H., & Vliegenthart, R. (2024). Distribution of solid lung nodules: Presence and size by age and sex in a Northern European nonsmoking population. Radiology, 312(2), e231436. DOI: 10.1148/radiol.231436.

 

RCT: Serratus anterior plane block reduces pain and opioid use in rib fracture patients – JAMA Surgery

2 May, 2024 | 23:20h | UTC

Study Design and Population:
This study was a multicenter, open-label, pragmatic randomized clinical trial conducted across eight emergency departments in New South Wales, Australia. The trial included 210 patients aged 16 years or older who had clinically suspected or radiologically confirmed rib fractures. Patients intubated, transferred for urgent surgical intervention, or with major concomitant nonthoracic injuries were excluded.

 

Main Findings:
In the trial, patients were randomized to receive either a serratus anterior plane block (SAPB) along with standard rib fracture management or standard care alone. The primary outcome was a composite pain score measured 4 hours post-enrollment. The SAPB group showed a significant increase in patients achieving the desired pain score reduction (41% in SAPB group vs. 19.6% in control; RR 0.73, 95% CI 0.60-0.89, P = 0.001). Additionally, SAPB recipients had significantly lower opioid consumption at 24 hours compared to the control group.

 

Implications for Practice:

The trial’s results support the addition of a serratus anterior plane block (SAPB) to standard rib fracture management for providing effective early pain relief and reducing opioid use. However, it’s important to note that this study did not include a sham group, and patients were aware of whether they received the intervention. This lack of blinding could influence patient-reported outcomes due to placebo effects. Despite this limitation, the reduction in pain and opioid consumption suggests that SAPB is a beneficial component of care for patients with rib fractures.

 

Reference (link to abstract – $ for full-text):

Reference: Partyka, C. et al. (2024). Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management The SABRE Randomized Clinical Trial. JAMA Surg. Published online May 1, 2024. DOI: 10.1001/jamasurg.2024.0969

 

M-A: Neoadjuvant chemoimmunotherapy enhances event-free survival in resectable NSCLC with low PD-L1 expression

28 Apr, 2024 | 20:20h | UTC

This meta-analysis evaluated the impact of neoadjuvant chemoimmunotherapy versus chemotherapy on resectable non-small cell lung cancer (NSCLC) patients, particularly focusing on those with tumor PD-L1 levels below 1%. The study synthesized data from 43 trials, encompassing 5431 patients, to assess clinical outcomes such as overall and event-free survival, alongside major and complete pathological responses. Findings highlighted that neoadjuvant chemoimmunotherapy significantly improved event-free survival (hazard ratio, 0.74; 95% CI, 0.62-0.89) compared to chemotherapy alone, particularly in patients with low PD-L1 expression, though overall survival benefits were not observed. The pooled analysis from randomized clinical trials showed favorable outcomes across all examined endpoints, supporting the superiority of neoadjuvant chemoimmunotherapy in these settings.

 

Reference (link to free full-text):

Sorin, M., Prosty, C., Ghaleb, L., et al. (2024). Neoadjuvant Chemoimmunotherapy for NSCLC A Systematic Review and Meta-Analysis. JAMA Oncology. doi:10.1001/jamaoncol.2024.0057.

 

Consensus Paper | Surgical video data use, structure, and exploration (for research in AI, quality improvement, and education)

9 Aug, 2023 | 15:20h | UTC

SAGES consensus recommendations on surgical video data use, structure, and exploration (for research in artificial intelligence, clinical quality improvement, and surgical education) – Surgical Endoscopy

 

Pictorial Review | Watch out for the early killers: imaging diagnosis of thoracic trauma

9 Aug, 2023 | 15:02h | UTC

Watch Out for the Early Killers: Imaging Diagnosis of Thoracic Trauma – Korean Journal of Radiology

 

Study | Removal of thymus in adults linked to increased death, cancer incidence

4 Aug, 2023 | 12:09h | UTC

Health Consequences of Thymus Removal in Adults – New England Journal of Medicine (link to abstract – $ for full-text)

Commentaries:

Doctors have long considered the thymus expendable. But could removing it be fatal? – Science

The thymus withers away after puberty. But it may be important for adults – Science News

Thymus gland critical for adult health, study finds – News Medical

 

Commentary on Twitter

 

NICE Updated Guideline | Diagnosis and management of lung cancer

4 Aug, 2023 | 12:05h | UTC

Lung cancer: diagnosis and management – National Institute for Health and Care Excellence

 

Study | AI use in lung cancer screening enhances prediction of lung cancer death, CVD death, and all-cause death

1 Aug, 2023 | 14:31h | UTC

AI Body Composition in Lung Cancer Screening: Added Value Beyond Lung Cancer Detection – Radiology (free for a limited period)

Commentary: Study: AI Assessment of Chest CT May Predict Multiple Mortality Risks – Diagnostic Imaging

 

BTS Guideline for pleural disease

31 Jul, 2023 | 14:44h | UTC

British Thoracic Society Guideline for pleural disease – Thorax

 

BTS Clinical Statement on pleural procedures

31 Jul, 2023 | 14:42h | UTC

British Thoracic Society Clinical Statement on pleural procedures – Thorax

 

Review | Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery

31 Jul, 2023 | 14:03h | UTC

Regional analgesia for acute pain relief after open thoracotomy and video-assisted thoracoscopic surgery – BJA Education

 

Systematic Review | Ethical perspectives on surgical video recording for patients, surgeons and society

11 Jul, 2023 | 13:44h | UTC

Ethical perspectives on surgical video recording for patients, surgeons and society: systematic review – BJS Open

 

RCT | Perioperative nivolumab plus chemotherapy increases pathological response vs. chemotherapy alone in stage III NSCLC

10 Jul, 2023 | 13:27h | UTC

Perioperative Nivolumab and Chemotherapy in Stage III Non–Small-Cell Lung Cancer – New England Journal of Medicine (link to abstract – $ for full-text)

Commentary: Addition of Neoadjuvant Nivolumab to Platinum-Based Chemotherapy in Stage III NSCLC – The ASCO Post

 

Commentary on Twitter

 

Editorial | How to become a good surgeon

22 Jun, 2023 | 15:12h | UTC

How to become a good surgeon – Advances in Ophthalmology Practice and Research

 

Guideline | Management of patients with primary spontaneous pneumothorax

20 Jun, 2023 | 12:46h | UTC

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV) – Respiratory Medicine and Research

 

Practice advisory for preoperative and intraoperative pain management of thoracic surgical patients

19 Jun, 2023 | 14:05h | UTC

Part 1: Practice Advisory for Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients – Anesthesia and Analgesia (free for a limited period)

Part 2: Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients – Anesthesia and Analgesia (free for a limited period)

See also: Prevalence and Characteristics of Persistent Postoperative Pain After Thoracic Surgery: A Systematic Review and Meta-Analysis – Anesthesia and Analgesia (free for a limited period)

Infographic: Persistent Pain After Thoracic Surgery—What Works, What Doesn’t – Anesthesia and Analgesia (free for a limited period)

 

RCT | Perioperative pembrolizumab improves pathological outcomes, event-free survival in early-stage NSCLC

6 Jun, 2023 | 14:36h | UTC

Perioperative Pembrolizumab for Early-Stage Non–Small-Cell Lung Cancer – New England Journal of Medicine (link to abstract – $ for full-text)

 

Commentary on Twitter

 

M-A | Comparison of intercostal block and epidural analgesia for post-thoracotomy

5 Jun, 2023 | 13:04h | UTC

Comparison of Intercostal Block and Epidural Analgesia for Post-thoracotomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials – Pain Physician (PDF)

 

Post-pneumonectomy syndrome: a systematic review of the current evidence and treatment options

15 May, 2023 | 12:45h | UTC

Post-pneumonectomy syndrome: a systematic review of the current evidence and treatment options – Journal of Cardiothoracic Surgery

 

RCT | Early NIV and HFNO therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients

10 May, 2023 | 15:48h | UTC

Early non-invasive ventilation and high-flow nasal oxygen therapy for preventing endotracheal intubation in hypoxemic blunt chest trauma patients: the OptiTHO randomized trial – Critical Care

 

RCT | Lung volume reduction surgery vs. endobronchial valves in patients with emphysema

2 May, 2023 | 13:29h | UTC

Lung volume reduction surgery versus endobronchial valves: a randomised controlled trial – European Respiratory Journal

 

Commentary on Twitter

 

RCT | Ventilation approaches in one-lung ventilation and pulmonary complications after major lung resection surgery

2 May, 2023 | 13:23h | UTC

One-lung ventilation and postoperative pulmonary complications after major lung resection surgery. A multicenter randomized controlled trial – Journal of Cardiothoracic and Vascular Anesthesia

 

Commentary on Twitter

 

RCT | The effectiveness of early surgical stabilization for multiple rib fractures

26 Apr, 2023 | 14:01h | UTC

The effectiveness of early surgical stabilization for multiple rib fractures: a multicenter randomized controlled trial – Journal of Cardiothoracic Surgery

Related:

RCT | Operative vs. nonoperative treatment of acute unstable chest wall injuries.

Surgical management of rib fractures after blunt trauma: a systematic review and meta-analysis of randomised controlled trials – Annals of The Royal College of Surgeons of England

RCT | Rib fixation is not beneficial for non–ventilator-dependent chest wall injuries.

 

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