What is the assessment and plan for hematology clearance for neurosurgery in a patient with a history of C1 fracture 8 months ago and a 4 cm Pulmonary Embolism (PE) exactly 3 months ago, whose 83-year-old mother has frailty, limited mobility, and foot drop?

From the Guidelines

Hematology Clearance for Neurosurgery

The patient with a history of C1 fracture 8 months ago and a 4 cm Pulmonary Embolism (PE) exactly 3 months ago should proceed with caution for hematology clearance for neurosurgery due to the recent thromboembolic event 1.

• The patient's recent PE puts them at high risk for another thromboembolic event, thus anticoagulation therapy should be carefully managed, preferably with a NOAC over the LMWH–VKA regimen unless contraindicated 1.
• Anticoagulation management is crucial: continue anticoagulation with a low molecular weight heparin (LMWH) such as enoxaparin 40mg subcutaneously once daily or unfractionated heparin, adjusted according to the patient's renal function and anti-Xa levels, until 24 hours before surgery.
• Mechanical prophylaxis with intermittent pneumatic compression devices (IPCDs) or graduated compression stockings should be used intraoperatively and postoperatively to prevent future thromboembolic events.
• A thorough coagulation profile including prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR), and anti-Xa levels if on LMWH should be performed preoperatively.
• The patient should be off anticoagulation for an appropriate period before surgery, typically 24 hours for LMWH, and the surgical team should be prepared for potential bleeding complications.
• Postoperative anticoagulation should be resumed as soon as safely possible, ideally within 24-48 hours, depending on the surgical site and the patient's risk of bleeding, as suggested by the guidelines for managing PE 1.
• Close monitoring of the patient's hematology parameters and clinical status is essential throughout the perioperative period to ensure timely intervention in case of any complications.
• The patient's mother's condition, although relevant for family support, does not directly impact the hematology clearance for neurosurgery.

From the Research

Assessment for Hematology Clearance

The patient has a history of C1 fracture 8 months ago and a 4 cm Pulmonary Embolism (PE) exactly 3 months ago. The following points are relevant for assessment:

• The patient's history of PE is a significant risk factor for venous thromboembolism (VTE) in the context of neurosurgery 2, 3.
• The use of heparin for VTE prophylaxis in neurosurgery has been shown to be effective in reducing the risk of DVT and PE, but it also increases the risk of postoperative hemorrhage 2, 3.
• The patient's age and medical history, including the recent PE, should be taken into account when assessing the risk of VTE and bleeding 4.

Plan for Hematology Clearance

The following points are relevant for planning hematology clearance:

• The patient's individual risk factors, including the history of PE and C1 fracture, should be considered when developing a plan for VTE prophylaxis 2, 3.
• The use of low-molecular-weight heparin (LMWH) or other anticoagulants may be considered for VTE prophylaxis, but the risk of bleeding should be carefully assessed 3, 4.
• The patient's mother's frailty, limited mobility, and foot drop are not directly relevant to the patient's hematology clearance, but may be relevant for overall patient care and management.
• Outpatient treatment with anticoagulants may be feasible for patients with acute PE, but careful selection and monitoring are necessary 5.
• The patient's recent PE and history of C1 fracture should be taken into account when developing a plan for neurosurgery, and individualized approaches to VTE prophylaxis and anticoagulation may be necessary 4, 6.