When should cataract surgery be scheduled relative to the patient's hemodialysis sessions to minimize bleeding risk while continuing apixaban?

Timing of Cataract Surgery Relative to Hemodialysis Sessions in Patients on Apixaban

Schedule cataract surgery on the day immediately following a hemodialysis session (within 24 hours after dialysis) while continuing apixaban without interruption, using topical or sub-Tenon's anesthesia.

Anticoagulation Management for Cataract Surgery

Continue apixaban through cataract surgery without interruption. 1 Cataract surgery is classified as a low-bleeding-risk procedure, and observational evidence demonstrates zero bleeding events when DOACs are continued through cataract surgery. 1 A 25-patient observational study specifically assessed DOAC continuation in patients undergoing cataract surgery and identified no bleeding events. 2

Evidence Supporting Continuation

• The American College of Chest Physicians 2022 guidelines classify cataract surgery among minor ophthalmologic procedures where anticoagulation continuation is safe. 2
• For warfarin therapy, guidelines explicitly recommend continuation around cataract surgery rather than interruption, with bleeding rates of approximately 10%, but almost all bleeds were self-limiting (dot hyphemas or subconjunctival bleeds) with no compromised visual acuity. 2
• Cataract surgery (phacoemulsification) is a largely avascular procedure. 2

Critical Anesthesia Consideration

Topical or sub-Tenon's anesthesia must be used—never retrobulbar anesthesia in anticoagulated patients. 1 Retrobulbar (intraconal) anesthesia poses significant concern due to the potential complication of retrobulbar hematoma, which can lead to loss of vision. 2 If retrobulbar anesthesia is absolutely required, hold apixaban for 1 day before the procedure. 1

Optimal Timing Relative to Hemodialysis

Perform surgery within 24 hours after the patient's most recent hemodialysis session. 3 This timing minimizes both surgical risk and dialysis-related complications:

Rationale for Post-Dialysis Timing

• Preoperative potassium values are significantly lower when patients undergo procedures within 24 hours of hemodialysis (mean 4.32 mEq/L) compared to more than 24 hours after dialysis (mean 4.63 mEq/L; P = 0.03). 3
• An institutional protocol ensuring elective surgeries occur within 24 hours after dialysis reduces procedural delays and cancellations caused by hyperkalemia and hypervolemia. 3
• When hemodialysis patients miss their routine dialysis, electrolyte abnormalities and volume overload frequently occur. 3

Avoiding the Post-Weekend Period

Avoid scheduling surgery on Monday (the first session after the two-day break) if possible. 4 After the two-day interdialytic interval, there are absolute increases in mortality (8.3 vs. 4.9 per 100 patient-years) and hospitalization (1.0 vs. 0.6 per year) compared to other days of the week. 4

Practical Scheduling Algorithm

1. Identify the patient's regular dialysis schedule (e.g., Monday/Wednesday/Friday or Tuesday/Thursday/Saturday). 4

2. Schedule cataract surgery for Tuesday, Thursday, or Saturday (the day after a dialysis session, avoiding the post-weekend period). 4, 3

3. Confirm topical or sub-Tenon's anesthesia will be used—document this explicitly in the surgical plan. 1

4. Continue apixaban without interruption through the perioperative period. 1

5. Ensure the patient attends their scheduled dialysis session the day before surgery—this is critical for electrolyte optimization. 3

Common Pitfalls to Avoid

• Never hold apixaban for routine cataract surgery with topical anesthesia, as this exposes patients to unnecessary thromboembolic risk without reducing bleeding complications. 1
• Never use bridging anticoagulation when stopping apixaban, as it significantly increases bleeding risk without reducing thrombotic events. 1, 5
• Never schedule surgery more than 24 hours after dialysis, as this increases the risk of hyperkalemia and volume overload. 3
• Never use retrobulbar anesthesia in fully anticoagulated patients due to the risk of vision-threatening retrobulbar hematoma. 2, 1
• Avoid scheduling on Monday (first session after the two-day break) when possible, as this timing is associated with higher mortality and hospitalization rates. 4