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The Interventional Radiology (IR) department services patients who need procedures that can be done with imaging guidance requiring only small incisions. This field is currently growing in size and scope as technology advances and more procedures are shifting from general surgery to IR (Bart et al. 2023). This rapid expansion is paralleled by the increasing amount of patients on antiplatelet and anticoagulant therapy (AAT) due to both chronic comorbidities and sudden acute thrombotic events (Rosenberg, 2022).
This policy concerns the growing intersection of people that require IR procedures while on AAT. These individuals have a much greater risk of adverse events such as bleeds requiring blood transfusions during procedures (Rosenberg, 2022), because there are currently no laboratory tests to determine levels of newer anticoagulants within the patients’ bloodstream (Jensen & Erikson 2018).
My name is Conrad Killer. I graduated in 2020 from the Indian River State College Associate Nursing Program and began my career as a Registered Nurse at Stuart Rehabilitation and Healthcare on the Covid Unit. After 6 months, I took a position on the trauma and neurology unit at Lawnwood Regional Medical Center. Shortly thereafter, I transferred to the inpatient rehabilitation unit where I remained for two years.
For the past 9 months I have been an imaging nurse at Cleveland Clinic working closely with Interventional Radiology. My previous positions all showed me the devastating power of ischemic strokes, hemorrhagic strokes, pulmonary embolisms, pneumothoraxes, and pleural effusions. I cared for people who would never walk, eat, or speak again. In my current position, I finally feel as though I can do something to save these people so they do not have to endure the fate shared by my other patients.
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Some of these patients are unable to have certain procedures, because they are on AAT for their other comorbidities. These patients must hold their AAT medications for a minimum amount of time or else they risk a hemorrhagic event, but withholding their medications for extended durations will increase their risk of a thromboembolic event (Patel et al. 2019). This leaves a small window of time where a procedure can be safely performed. This policy aims to unify IR departments on a national level to best utilize that window thereby reducing the number of adverse events in the future.
All patients scheduled for any IR procedure must be evaluted for hemorrahgic risk. If the patient and procedure are both not a high risk for bleeding, then they may continue their current AAT as normal. If either the patient or procedure are determined to be high risk, then AAT must be held for the corresponding number of days for the medication.
Patel et al. 2019
A patient is considered to be a high risk for bleeding if they possess three or more of the following:
The following are procedures that are considered to have a high risk of bleeding complications:
(Patel et al. 2019)
Do not withhold - Cilostazol (Pletal)
1 hr - Cangrelor (Kengreal)
4 hr - IV heparin, Argatroban (Acova), Bivalirudin (Angiomax),
6 hr - Subcutaneous heparin
8 hr - eptifibatide (Integrilin), tirofiban (Aggrastat)
24 hrs - Long-acting abciximab (ReoPro), Enoxaparin (therapeutic dose)
1 dose - Lovenox (prophylactic), Dalteparin,
2 doses - Edoxaban (Savaysa), Rivaroxaban (Xarelto)
3 doses - Betrixaban (Bevyxxa)
4 doses - Apixaban (Eliquis), Dabigatran (Pradaxa)
3 days - Fondaparinux (Arixtra)
5 days - Aspirin 325mg, Aspirin/dipyridamole (Aggrenox), Clopidogrel (Plavix), Ticagrelor (Brilinta), Warfarin (Coumadin)
7 days - Prasugrel (Effient)