Cambridge Breast Unit Protocols for anticoagulant management prior to breast or axillary biopsies or excisions.

Transcription

1 Prtcl CBU/POL/ JOINT POLICIES/008 Octber 2017 Prtcls fr anticagulant management prir t breast r axillary bipsies r excisins. 1. Scpe Fr use in the in bth screening and symptmatic breast services. 2. Purpse T prvide a framewrk t maximise patient safety, risk management and benefit t the rganisatin by understanding when t stp anticagulatin prir t breast and axillary bipsies and excisins. 3. Backgrund Advice fr stpping anticagulatin prir t breast and axillary bipsies / excisins des nt easily fit int surgical and interventinal categries. Cmpared t ther interventins, these bipsy carries a lw risk f significant bleeding. Due t the lcatin f the bipsy, adequate haemstasis can nrmally be achieved by direct cmpressin f the bipsy site (+/- use f an ice pack). There is evidence that haematma frmatin has n clinically significant difference if the patient is anticagulated, cmpared t if they are nt. Unnecessary cessatin f anticagulatin may pse greater risk t patients than its cntinuatin. 4. Guidance Patients shuld be asked prir t a bipsy r vacuum assisted bipsy r excisin if they are taking anticagulatin. This will then guide the radilgist t the safest apprach t either cntinuing, stpping r seeking further guidance befre the bipsy. Newer anticagulants, the direct ral anticagulants (DOACS are excreted renally and therefre their level, and in turn hw lng they need t be mitted fr, is dependant n renal functin. The British Sciety f Haematlgy recmmends that the amunt f time a DOAC shuld be mitted fr is dependent n creatitine clearance. An estimated creatinine clearance can be calculated using patient s age, serum creatinine and weight (see frmula belw)

2 If creatinine clearance is nrmal then the DOAC can be stpped fr 24 hurs prir t the. If it is abnrmal then it wuld need t be mitted fr lnger, as per table 2 belw. The DOAC can be restarted at nrmal dse the day after the. If there is any clinical cncern regarding the cessatin f the anticagulatin, r if further guidance is required then the duty haematlgist shuld be cntacted n a case by case basis. There are ther rare situatins, e.g. patient is n Tinzaparin r intravenus heparin. There are n set guidelines fr these and they shuld be discussed n a case by case basis. If bipsy cannt be delayed until anticagulant is ceased, advice shuld be sught frm the duty haematlgist. The tables belw cmbine the guidance frm BSBR (2) and British Sciety Haematlgy (1): Table 1. Warfarin Cre bipsy breast r axilla INR <4 Cn*nue medica*n INR> 4 stp warfarin 24 hrs befre and repeat INR Vacuum assisted bipsy r excisin ( VAB,VAE) INR <2.5 Cn*nue medica*n INR>2.5 stp warfarin fr 24 hrs befre and repeat INR Aspirin/Clpidgrel Cn*nue medica*n Cn*nue medica*n DOACs (eg dabigatranm rivarxaban,apixaban, edxaban) NORMAL RENAL FUNCTION DOACs (eg dabigatranm rivarxaban,apixaban, edxaban) ABNORMAL RENAL FUNCTION Other ankcagulants Stp fr 24 hurs befre Restart day after Stp fr 48 hurs at least befre Restart day after Seek advice frm duty haematlgist Stp fr 24 hurs befre Restart day after Stp fr 48 hurs at least befre Restart day after Seek advice frm duty haematlgist Table 2: Cmmn anticagulants and fr ceasing medicatin.

3 Drug Renal functin (Creatinine clearance CrCl, ml/min) Hurs t stp befre DABIGATRAN t < t < RIVAROXABAN, APIXABAN, EDOXABAN <30 48 Table 2: DOAC, creatinine clearance and number f hurs drug shuld be stpped befre Calculatin f Creatinine Clearance CrCl = Fx (140-age) x weight (kg) Serum Creatinine (micrmles/l) Where F= 1.04 fr females, 1.23 fr males IF THE PATIENT IS AT HIGH RISK OF THROMBOEMBOLISM THEN STOPPING ANTICOAGULATION MAY BE HARMFUL AND BRIDGING HEPARIN MAY BE NEEDED. ADVICE MUST BE SOUGHT FROM MEDICAL HAEMATOLOGY SpR ONCALL. SEE BELOW. High risk f thrmbemblism DVT r PE in the previus three mnths Recent strke/tia in the last 6 mnths Antiphsphlipid syndrme with histry f arterial thrmbsis. Deficiency f prtein C, prtein S, r antithrmbin Patients at high risk f recurrent VTE (e.g target INR 3.5) Atrial fibrillatin and knwn mitral stensis Atrial fibrillatin with a CHA2DS2-VASc scre f 5

4 Artic valve with ne r mre f the fllwing risk factrs AF Prir strke/tia Hypertensin Diabetes Cngestive heart failiure >75yrs Mitral valve r caged ball/tilting disc artic valve Patients within 1 mnth f bare metal stent and 12 mnths f drug eluting stent insertin. 5. Mnitring cmpliance with the effectiveness f this dcument a) Prcess fr mnitring cmpliance and effectiveness: Review f Safety Learning Events, as recrded n the Trust QSIS reprting system, fr nncmpliance and the results presented t the Patient Safety & Gvernance grup - the minutes f these meeting are retained fr a minimum f 5 years. b) Standards/Key Perfrmance Indicatrs: This prcess frms part f a quality system accredited t Internatinal Standard BS EN ISO 9001:2015. The effectiveness f the prcess will be mnitred in accrdance with the methds given in the quality manual (QM1.00). 6. References 1. British Sciety f Breast Radilgists guidelines 2012 Prtcl fr breast bipsy in patients taking anticagulant and antiplatelet therapy /9895/6729/bipsy_guidelines_jul_2012.pdf 2. British Sciety Haematlgy guidelines 2016 Periperative management f patients n anticagulant and antiplatelet therapy.

5 3. Chetlen AL et al. Hematma frmatin during breast cre needle bipsy in wmen taking antithrmbtic therapy. AJR, 2013;201: Cntributrs and peer review Dr Emma Senir, Cnsultant Radilgist and Directr f Breast Screening West Sufflk Hspital NHS Trust Dr William Thmas, Cnsultant Hematlgist Cambridge University Hspital 7.Equality and Diversity Statement This dcument cmplies with the Cambridge University Hspitals NHS Fundatin Trust service Equality and Diversity statement. Disclaimer It is yur respnsibility t check against the electrnic library that this printed ut cpy is the mst recent issue f the dcument. Dcument management. Apprval: Penny Myle Date apprved: 3/10/17 Date n e-library: Owning Department: Authr(s): File name: Dr Penny Myle and Dr William Thmas CBU_POL_JOINT_POLICIES_008_Anticagulatin_Breast_Bipsy_Final_PLM_ Keywrds: Anti Cagulatin Breast Bipsy Final PLM Review perid: 3/10/18 Revisin number: 1 Lcal reference: CBU/POL/JOINT POLICIES/008 Media ID: T reference the latest versin f this dcument use the link n Lcal reference/mediaid abve