Coagulation

Abstract

Coagulopathy may be a life-threatening complication of any emergent operation. This is particularly relevant with the aging population who frequently are consuming preoperative anticoagulation or antiplatelet therapy. The most effective method to avoid coagulation-related complications is to obtain an accurate list of medications and their specific indications. A significant number of patients are unaware of the indications for their ongoing therapy, and their medication can simply be terminated or potentially reversed if a high-risk operation is required. Unfortunately, under emergent conditions due to sepsis or acute blood loss there is no opportunity to obtain a thorough or reliable history. In this scenario, perioperative coagulation assessment is important, but may require special testing with FXa and thrombin inhibitors. A massive transfusion (>4 U RBC/h) is invariably associated with a coagulopathy and warrants evaluation as soon as the risk is identified. Traditional coagulation tests (PT/INR and aPTT) are excellent biomarkers for transfusion, but viscoelastic assays (TEG/ROTEM) are optimal to treat the multitude of coagulopathy phenotypes. At the same time, hypercoagulability is common among patients surviving massive transfusion and thus VTE prophylaxis is also important in critically ill patients.

KPI title: Patients requiring an emergent operation on warfarin therapy should have an international normalized ratio (INR) measured at the time of initial assessment

Description	INR measurement
Rationale	An emergent operation can be complicated with bleeding which may be accentuated due to warfarin therapy because of inadequate concentrations of clotting factors II, VII, IX, and X.
Target	100% of patients undergoing an emergent operation on warfarin therapy have a preoperative INR measured.
KPI collection frequency	Annually
KPI reporting frequency	Annually
KPI calculation	Numerator: number of patients undergoing an emergent operation on warfarin therapy who have a preoperative INR measured Denominator: number of patients undergoing an emergent operation on warfarin therapy
Reporting aggregation	Hospital 1
Data source(s)	Emergency surgery database ICU database