0:01

So coagulopathy and bleeding risk

0:02

is something that's very important.

0:03

So let's ask a few questions just

0:05

to sort of clear the air and sort of

0:08

really validate our fund of knowledge.

0:10

So when should heparin infusions be

0:13

stopped right before an arterial puncture?

0:16

So right before?

0:19

Is that an option?

0:20

It's an option.

0:21

What about at least 30 minutes before?

0:24

What about at least 2 hours before?

0:26

So if you thought that it was at least 2

0:29

hours before, you'd be absolutely right.

0:30

So, the half-life of heparin is about two hours, and

0:33

so, really, heparin infusion should be stopped

0:35

at least two hours prior to the arterial puncture.

0:37

So, for patients receiving the therapeutic

0:38

doses of heparin, the scheduled dose prior

0:40

to the procedure is usually withheld.

0:43

So, what laboratory test is used to track

0:45

the level of anticoagulation of a patient

0:47

with heparin therapy, and whether it is

0:49

acceptable for routine arterial access?

0:52

Well, both partial thromboplastin

0:54

time and activated clotting

0:55

time (ACT) can actually be used.

0:57

And if ACT is less than 180, usually the threshold

1:02

that sort of allows us to say above, a little

1:04

bit more bleeding risk below, all set.

1:07

So when can heparin therapy be restarted?

1:09

So heparin therapy can actually be restarted

1:11

about two to four hours after an arteriovenous

1:12

sheath or a catheter has been removed.

1:16

And successful hemostasis is

1:18

usually achieved via manual compression.

1:20

So once that manual compression

1:22

occurs, hemostasis is achieved.

1:23

Now start that 2 to 4 hours, and then

1:25

you may start that heparin,

1:27

or restart that heparin at that point.

1:30

It could be initiated early in patients

1:32

that receive a vascular closure device.

1:34

Just want to make sure that's flagged so

1:36

everybody's aware that that is a little

1:38

nuance that we want to be mindful of.

1:41

So when should warfarin be stopped

1:42

prior to arterial puncture?

1:45

3 to 5 days is truly the standard

1:48

time when warfarin should be held.

1:50

And 5 days is pretty much what I would say

1:52

probably 97 percent of individuals would say to you.

1:57

So what medication can be administered

1:59

to expedite a necessary procedure

2:01

for a patient who's actually on warfarin?

2:03

So if it's a non-urgent intervention, you

2:06

may say, "Oh, okay, let's go with the vitamin K,

2:07

the IV, or the PO."

2:10

But if you're saying, "You know what, this

2:11

is a case on call patient who's on warfarin

2:14

trauma, this bleeding is going to be, you know,

2:18

really provoked and exacerbated by

2:21

the fact that this patient is on Coumadin."

2:23

So let's do a little bit of reversal here.

2:25

And give fresh frozen plasma or

2:27

prothrombin complex concentrate.

2:29

And I would say that would

2:30

probably be the right answer.

2:32

And the goal, of course, as we

2:33

mentioned before, is often less than 1.5

2:35

for arterial and less than 2 for venous access.

2:39

So what is the management for an outpatient

2:40

who cannot discontinue warfarin therapy

2:43

because they have a prosthetic heart valve,

2:45

but they require this arterial

2:47

access for an intervention?

2:49

So, if you want to transition a patient to low

2:51

molecular weight heparin, which can actually

2:53

be stopped two hours before the procedure,

2:55

that may actually be a good thing, because in

2:58

situations where you discontinue warfarin

3:01

for five days before a patient that has a

3:02

prosthetic heart valve, that may actually not

3:06

be great for this specific scenario, where a

3:08

patient actually needs that warfarin therapy

3:11

because of this prosthetic heart valve.

3:13

But you also want to protect your

3:15

procedure, your periprocedural window.

3:17

So you get this sort of anticoagulation

3:20

allowing the patient to be on anticoagulation

3:22

right after the procedure by transitioning

3:24

them to low molecular weight heparin.

3:27

But then, you transition them

3:29

back to warfarin after the procedure.