AF on apixaban for bleeding bladder tumour81-year-old man, 76 kg, with a bleeding bladder tumour for time-sensitive endoscopic resection

The patient

The examiner asks

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1. Consider

   What matters in this man?

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   • An 81-year-old on apixaban with a past stroke, for time-sensitive resection of a bleeding bladder tumour. Patient
   • At 81, after a stroke and with clearance 40, his delirium risk is high; I screen cognition first.
   • Urgency: time-sensitive, so tomorrow's slot gives time to assess, not to delay. Stem trigger
   • Active cardiac conditions? None: his AF is rate-controlled at 84 and he isn't in failure. Disease
   • Risk score: his stroke is his only RCRI item; this isn't intraperitoneal surgery. RCRI 1.
   • Functional capacity: two flights of stairs, slowly, so over 4 METs.
   • Decision: RCRI 1, so no further cardiac tests; the real decision is his anticoagulation.

2. Prepare

   How will you manage his anticoagulation?

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   • His CHA2DS2-VASc is 5: age and stroke count double, plus hypertension. Disease
   • Bleeding risk is high too: active haematuria, age and reduced kidney function.
   • No heparin bridge; in AF it adds bleeding without stroke benefit.
   • Thirty hours since apixaban: anti-Xa or apixaban level; nothing measurable means no reversal.
   • Continue bisoprolol so his rate stays controlled through the hospital stay.
   • Agree timing and a restart plan with urology and his cardiologist beforehand.
   • Crossmatch, and have PCC and tranexamic acid ready in theatre. Crisis

3. Plan

   Spinal or general anaesthesia?

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   • Spinal is out; apixaban needs at least 72 hours off before a neuraxial block. Disease
   • General anaesthesia; induction with reduced propofol, under 1.5 mg/kg, for his age.
   • Lateral wall tumour: full relaxation stops the obturator jerk; an obturator block is deep, so also 72 hours. Surgery
   • Keep his pressure near baseline given his stroke history. Disease
   • Apixaban restarts 48–72 hours after this high-bleeding-risk procedure, once urine clears. After surgery

4. Crisis

   During resection the irrigant turns frankly bloody; BP 84/50, HR 118, Hb 7.2 g/dL. What do you do?

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   • Massive haemorrhage: frank bleeding, BP 84/50, HR 118, Hb 7.2, in an 81-year-old on apixaban. Crisis
   • Call for help; urology controls the bleeding point; massive transfusion protocol activated.
   • Two large-bore lines; red cells, plasma and platelets close to 1:1:1, all warmed.
   • Tranexamic acid: 1 g IV, given over 10 minutes.
   • His apixaban branch: andexanet alfa if stocked, otherwise four-factor PCC.
   • Ionised calcium checked as citrated blood runs; keep him warm and correct acidosis.
   • HDU afterwards; anticoagulation restarts jointly with urology and cardiology. After surgery