How to manage a high-risk appendectomy in a patient with recent NSTEMI, stopped double antiplatelet therapy and anticoagulant, with leukocytosis and thrombocytopenia?

From the Guidelines

The patient should undergo a laparoscopic appendectomy as soon as possible, with careful perioperative management, including cardiology consultation to determine optimal antiplatelet therapy, and consideration of bridging with a short-acting antiplatelet agent like tirofiban or eptifibatide, as the risk of appendiceal rupture likely outweighs bleeding concerns. The patient's recent NSTEMI and discontinued antiplatelet/anticoagulant therapy increase the risk of cardiac complications, while the leukocytosis and thrombocytopenia require careful management to prevent bleeding and thrombotic complications.

• Key considerations include:
  • Continuing aspirin perioperatively (81mg daily) while temporarily holding P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) 1
  • Bridging with a short-acting antiplatelet agent like tirofiban or eptifibatide may be considered for very high cardiac risk patients, as seen in the case described by 1
  • Intraoperatively, meticulous hemostasis is crucial, potentially using hemostatic adjuncts like topical thrombin or fibrin sealants
  • Thrombocytopenia should be addressed with platelet transfusion if counts are below 50,000/μL
• Postoperative management should include:
  • Restarting P2Y12 inhibitors within 24-48 hours if hemostasis is adequate, with close monitoring for both bleeding and thrombotic complications 1
  • Early mobilization, pneumatic compression devices, and prophylactic heparin (once bleeding risk decreases) to prevent venous thromboembolism
  • Close monitoring of the patient's cardiac status and bleeding risk, with adjustments to antiplatelet therapy as needed, as recommended by 1 and 1

From the FDA Drug Label

WARNINGS ... Hemorrhage can occur at virtually any site in patients receiving heparin ... Heparin sodium should be used with extreme caution in disease states in which there is increased danger of hemorrhage ... Some of the conditions in which increased danger of hemorrhage exists are: ... Hematologic—Conditions associated with increased bleeding tendencies, such as ... thrombocytopenia Thrombocytopenia has been reported to occur in patients receiving heparin with a reported incidence of up to 30%. Platelet counts should be obtained at baseline and periodically during heparin administration.

La paciente tiene trombocitopenia (122.000 plaquetas) y se planea una apendicectomía de alto riesgo. El uso de anticoagulantes como la heparina debe ser cuidadoso en pacientes con trombocitopenia debido al aumento del riesgo de hemorragia.

• La decisión de administrar anticoagulantes debe ser tomada con precaución, considerando el riesgo de hemorragia y el beneficio de prevenir la trombosis.
• Se debe realizar un seguimiento cercano de los recuentos de plaquetas y la coagulación para minimizar el riesgo de complicaciones.
• La heparina debe ser utilizada con extrema precaución en pacientes con trombocitopenia y se debe considerar la posibilidad de utilizar alternativas anticoagulantes si es necesario 2.

From the Research

Management of High-Risk Appendectomy

The patient in question is a 66-year-old woman with acute appendicitis and NSTEMI, who recently stopped double antiplatelet therapy and anticoagulant. The current leukocyte count is 36,000, and platelet count is 122,000.

• Perioperative Management: According to 3, the perioperative management of patients on anticoagulant and/or antiplatelet therapy is complex. The study suggests that monotherapy with clopidogrel or aspirin need not be discontinued in elective non-CPB surgery. However, in this case, the patient has recently stopped double antiplatelet therapy, and the surgery is considered high-risk.
• Bleeding Risk and Antiplatelet Therapy: The study 4 highlights the importance of considering the underlying risk of bleeding when managing patients on dual antiplatelet therapy. The patient's high bleeding risk, combined with the recent cessation of antiplatelet therapy, increases the risk of adverse events.
• Continuation of Antiplatelet Therapy: The study 5 suggests that antiplatelet therapy should be continued in patients at risk of myocardial infarction, as the risk of coronary thrombosis after withdrawal is higher than the risk of surgical bleeding. However, this may not be feasible in this case, given the patient's high-risk appendectomy.
• Tranexamic Acid and Platelet Function: The study 6 found that tranexamic acid can partially improve platelet function in patients treated with dual antiplatelet therapy. This may be a consideration in managing the patient's bleeding risk.
• Antiplatelet and Anticoagulant Drugs: The study 7 provides an overview of antiplatelet and anticoagulant drugs used in interventional radiology. The study highlights the importance of understanding the pharmacologic properties of these drugs to manage patients effectively.

Key Considerations

• The patient's recent cessation of double antiplatelet therapy and anticoagulant increases the risk of adverse events.
• The high bleeding risk and thrombocytopenia require careful management to minimize the risk of bleeding complications.
• The use of tranexamic acid may be considered to partially improve platelet function.
• A multidisciplinary approach, involving cardiologists, anesthesiologists, and surgeons, is essential to manage the patient's care effectively.