Acitrom (Acenocoumarol) Holding Time for Bronchoscopy with BAL
Oral anticoagulants like Acitrom (Acenocoumarol) should be stopped at least 3 days before bronchoscopy when biopsy specimens may be required, or the anticoagulant should be reversed with low-dose vitamin K. 1
Anticoagulation Management Protocol
Standard Recommendations:
- For diagnostic bronchoscopy with BAL (bronchoalveolar lavage):
- Stop Acitrom (Acenocoumarol) at least 3 days before the procedure
- Check INR before the procedure to ensure it has normalized
- Resume Acitrom after the procedure once hemostasis is confirmed
Special Circumstances:
- For patients with high thromboembolic risk where anticoagulation must be continued:
- Reduce INR to <2.5
- Consider bridging with heparin 1
- Consult with cardiology/hematology for individualized bridging protocol
Risk Assessment
Bleeding Risk Factors:
Procedure-related:
- Transbronchial biopsy carries higher bleeding risk than BAL alone
- Multiple biopsies increase bleeding risk
Patient-related:
- Uremia
- Liver disease
- Concurrent antiplatelet therapy
- History of bleeding during previous procedures 2
Laboratory Monitoring:
- Check platelet count, prothrombin time, and partial thromboplastin time before performing transbronchial biopsies 1
- For routine bronchoscopy without biopsy, these tests are only required in patients with known risk factors 1
Practical Considerations
Pre-Procedure:
- Establish intravenous access before starting the procedure 1
- Ensure resuscitation equipment is readily available 1
- Monitor oxygen saturation throughout the procedure 1
Post-Procedure:
- If transbronchial biopsy was performed, obtain a chest radiograph at least 1 hour after to exclude pneumothorax 1
- Provide verbal and written instructions about potential delayed complications 1
- Resume Acitrom only after confirming absence of bleeding
Important Caveats
- While some studies suggest bronchoscopy can be performed safely in patients with thrombocytopenia 3, anticoagulation presents different risks and should be managed more cautiously.
- The recommendation to stop oral anticoagulants 3 days before bronchoscopy is based on moderate-quality evidence (level B) from the British Thoracic Society guidelines 1.
- For patients who cannot stop anticoagulation due to high thromboembolic risk, close coordination with the anticoagulation service is essential to manage the bridging therapy.
Remember that even small amounts of bleeding in the airway can have serious consequences, so proper management of anticoagulation before bronchoscopy is critical for patient safety.