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I was just letting the last few come through and then we'll get started. Okay? Can I just someone put in the chart whether you conceive the front page of my present patient, please. Lovely. Thank you, but true. Okay. Um, I'll make a stop. Um, thank you. Um and, um, I've got my phone here with the chat open. So, um, I will be able to answer questions on I would like you guys to interact as much as you can. Um, I have these platforms mean there's a little bit less interaction, but I'm going to try my best, because this topic is actually fairly complex and fairly new once, too. And I'm sure it's a little bit difficult for a lot of us. I personally find it quite challenging. And I've been on two, um, sagittal rotations at the moment. I don't know about you guys. I find that different. Senior doctors have different ways of doing things on Because of that previous experience, they might not always stick rigidly to the guidelines. So I'll try my best to sort of incorporate all of that. So, just a little bit about the orthopedic teaching series so far So you've had neck femurs. You had ankle fractures, spinal emergencies, wrist and forearm on today. We're doing with reading on anti coagulation. So I am sira. I'm head of surgery at mind The bleep, um on. I'm really proud of my colleagues, Omar, and worry for a fantastic job they've been doing with, um, this orthopedic Siris. I hope you've been enjoying it and then, um, been able to tune in and everything's recorded. So feel free to access after and then also feel free to contact me if you wanted to give me any feedback or wanted to talk about anything. Um, so I'm in academic F one in the Oxford eatery. At the moment I did general surgery as my first F one rotation general medicine, And I've just moved onto tiene Oh, so, um, that's why this is quite useful. I actually delivered this teaching earlier today to my colleagues. I've got some very helpful feedback off thumb which I've been able to apply and implement, and hopefully it will give you a better experience as well. So other things I do I conclude two different Q. I projects up both the hospitals I work out um, head of surgery and finance. I'm also the finance medic. Um, so do you follow me on instagram and get lots of tips on how to manage your money as a doctor? Um, Andi, I'm also mommy slash the person who buys the treats for my two lovely little doggies. So after this presentation, you should be able to optimize the patient's anti coagulation for surgery prescribed pre and post surgery from a purple axis on. Identify which members of the team you'll need to consult in special circumstances. We're going to focus our presentation on orthopedics, specifically part the tnm Oh area. And actually, things will defer for other operative procedures, so I I will touch on them a little bit, but I can give you some guidance of where to find information. Um, your organization's internal guidelines are the best place to get an idea of what your organization likes to do. What I've done is I've combined really good guidelines that I found for Wolverhampton, which were written by a consultant, hemotologist, and consultant surgeon. So I've, um, album ated that with some of the guidelines that were a bit more generic for my trust, Um and to try and create a sort of go to resource that you can use when you're stuck. So the first port, of course, will always be your own guidelines of your trust. But then, if you're finding it really difficult to figure it out or you just have not not sure about something you could have a look at my resource is and see whether it, you know, your understandings sort of write. It kind of reflects what the consensus is across the board. So why do we care about anti coagulation? Well, um VT. So DVTs and peas are a recognized complication off the fact that surgical procedures put you on a hypercoagulable state on they can cause a significant amount off immobilization, which again is another risk factor. A lot of them are preventable on that. They have been several serious incidents, which has prompted arm or robust approach to VT prophylaxis, both preoperatively and postoperatively on. We tend to postoperatively anti calculate for a significant period of time because patients rehabilitation contain different periods of time based on their own baseline, on also the procedure that they've been through. So even before you decide what kind of chemical anti coagulation to use for your patient. They're they're simple things that are really inexpensive and actually very straightforward to try and help thumb not have a DVT or a P. So things like TEDs or anti embolism stockings you just have just make sure that they can wear them. So, for example, make sure they don't have any cellulitis. Um, peripheral edema that might cause a problem. Having the anti embolism stockings, um, any wounds, ulcers, anything that's stopping them, having them. You could easily just have a quick look at their feet on. That's an easy way to start your journey in calculating them. Flowtrons are similar. My except they just inflating deflates. So they basically the actors an artificial solace on. Do they just pump the carbs for the patient on? Then again, you can encourage patients to do foot pumping on, moving their feet around in their legs around what's there in bed, just to make sure that it prevents them getting blood clots. Um, then, whilst you are doing all of this, you can request, um, investigations. So I in our would be the main thing, which would be part of your clotting screen a full blood count for the hemoglobin and platelets. Um, you would want to do using these and get their weight, because for a lot of anti coagulation, you need to calculate the creatinine clearance on will come to why this is important, um, on a group and save if it's indicated so the hemoglobin, for example, will give you an idea or the type of operation they're having. So I've told your hip replacement, for example, will result in quite significant blood loss. So they will need a group and save, however on, or if for a distal radius fracture will probably have minimal bleeding. And some trusts may not request a group and say so. It's always it's always based on the procedure itself on what your trust does. So next thing is in my head, there's three types of patients that come through the door patients who are already taking anticoagulants. So that, to me, is probably a slightly more complex issue. Because, you know, I only have to balance the anticoagulants they're already taking, which then creates a bleeding risk. But you also have to make sure that you're putting them back on the anticoagulants that they came in with at the right time at the right dose. The next thing is patients who you might not have thought had an increased from both this risk, but actually do on. So you might consider a slightly more strong, um, anti prophylaxis. Or you might consider slightly more prolonged from a prophylaxis after they've been discharged and then the patients with no additional risks for Moses. So we're gonna think of this in a pre op and postop away because we have to deal with the anti coagulation going up to the procedure on then the anticort. The key things we want to keep in mind preop is what medications are there on on what dosages off those medications are they taking? What is that weight? So that can help us calculate the creatinine clearance using they're using these. What is the V, t and medical history? So, for example, someone who had on ah, you know on on a provoked DVT 10 15 years ago might know actually be very high risk in terms of your risk stratification when it comes to calculating how much anticoagulation to give and then what they call moderate disease are. So things like a f will mean that they're probably on some sort of does work or warfarin. If they have a mechanical valve, they will probably be on warfarin. Um, Andi, they might be on some sort, some kind of medication that might contraindication kinds of prophylaxis. So, um, finito in and other anti epileptics, for example, um, have drug interactions with doakes. So patients who need to be anticoagulated after for a prolonged period of time can actually go on docks. And we'll need to go on warfarin, for example. So, you know, just having a background of epilepsy might bring some alarm bells. That and then afterwards we see them POSTOP eso POSTOP, how much blood they have lost. That's information that would be in the POSTOP note what that bleeding risk is now. This is based on how the operation went, what the initial, um, iron are and bleeding risk. Waas, which you'll be able to risk stratify on the surgeon might give you an indication of whether there was written here and vascular injury. That might mean there's a prolonged bleeding risk, and then again, you need to keep recalculating the creatinine clearance because as they go through the POSTOP period, they might end up with an A k I, for example, on that will change their creatinine clearance. So ongoing monitoring it means that you might have to adjust the doses of your POSTOP anti coagulation. So, um, don't panic at this page. Basically, I'm just showing you how to assess the form bosses and bleeding risk. So the first bit is the thrombotic risks, or how likely they are to get a blood clot on the 1st. 2nd bit is how likely are they are to bleed after the surgery. So this is from the Wolverhampton guideline on. Basically, the reason I've circled those two things is to say that most of our patients, actually in terms of the some voices risk fall into the low risk category. Low and moderate risk they usually have, Um, if they have a V T history attempts to be provoked. If they have a f, you know it tends to be controlled eso, for example, these kind of things. They tend to be at the lower moderate risk size, but do keep an eye on the things like the high risk and the very high risks. The ones that have metallic valves. Those who've had VT in the past six weeks, 6 to 12 weeks, for example, those you have non value. Excuse me, valvular a f um, with a child vascular five or six, for example, these will these patients will present on they will have to be considered as part of a no overall approach to that monitor mint. Next is a bleeding risk. Another reason I have circled high is because in that in that list says major orthopedic surgery. So this is anything I think hips are always major. Knee replacements are major. Um, so to me, just keeping an, um, I in the back of your mind that actually they are a higher bleeding risk because of this. But there are other procedures, like on or if for a distal radius fracture, where the bleeding risk is relatively low. Eso it would be worth sort of just keeping that in mind that the back of your mind, but knowing that most of our patients, the ones who have the hip replacements, are usually a high risk of quite significant bleeding. So you might be wondering How the hell am I supposed to risk stratify these patients? Well, um, to start to you can get an idea by using chad. Mask on has bled. Um, so if you don't have any Kulka yet, please get it. It's very good. I use it for all my scoring systems. Um, on. So you use your child law school to assess their VT risk. And then if we go back to that guy in line, for example, it gave you a very specific example that people with non valvular a, uh, with a child vascular five or six considered high risk for thrombosis on. Then you can apply that to the rest of your assessment. Um, your guideline at your trust might actually specify certain numbers that the school should be. Um, other times you can personally use the child Baskin husband school to create a bit of a picture in your head of highlight how likely this person is to develop a blood clot on how likely they are to bleed after surgery. So apologies for how busy this slide looks. But actually, what I did was I condensed several different resource is into one table, so that it could show you how to manage preoperative patients already on the different type of anticoagulants on one page. So then you can actually print this out. So, um, feel free to screen shot. This, um, on different out. What I might actually do is provide a pdf copy to go on the minds bleed website, Um, so that you can print this out yourself. So if we want through each bit individually, it actually is a lot easier. So, for example, if you have a patient who comes in on warfarin, I've never heard of the other two. So warfarin is the one I'm sticking right? Basically, what you want is for their iron, are to be less than 1.5 on the day of surgery. That's your target. Specifically, if you remember our learning outcomes, we talked about which specialists he'd want to approach and why? Well, if a patient has a metallic heart valve there an increased risk of of ETAC. So you want to discuss with the cardiologist If the patient has is on dialysis, then there a significant risk bleeding risk because they won't be able to clear the antique wagons as much as someone else who doesn't have renal problems. So discuss that with the renal team. Basically, the consensus is to stop warfarin five days before surgery. Take the iron are one day before surgery. If the iron are is over 1.5, then the surgery could be delayed. Or you can give them vitamin K here, it says. And in the guidelines it says, speak to a hematologist for advice about the dose of vitamin K. Now, in our trust, we've gone also, geriatrician, we got three of thumb they do this day in and day out so they'll know it well. So you know, if you're stuck if you have nowhere to go, contact your hematologist, but actually check on the ward. You might have senior doctors who already know what to do in this situation. So we talked about VT risk on a person with a higher VT risk. So someone who, for example, has high chads score or someone who might have had a recent unprovoked the tea. Um, you might want to bridge them with low molecular weight heparin between stopping their warfrin on their operation. So here it suggests that you stop warfarin five days beforehand. You wait two days on, then three days before the operation. You, um give thumb low molecular. It happens or dull two parent or fragment, whatever you're using, your trust on the prophylactic slash treatment dose is basically based on how high they're risk is. If there are moderate risk, give them for overactive dose for the three days before the operation, omitting the morning of the operation or if they're very high risk, you give them treatment, dose all different. And then, um, it it on the morning of the operation. So actually, warfarin is no a scary anymore that I would see a patient coming on warfarin and be like, Oh, my God, what am I gonna do? But actually, this is very straightforward on being able to monitor the iron are really helps to keep keep me grounded in terms of what I need to focus on, and that really helps. The next thing is apixaban rivaroxaban the bigger transfer. The door works now. This is very common. A lot of people are on this now, so if the person has a low bleeding risk, which you can use the chance of us that the has bled score to decide. Then you can stop the DOAC 18 to 24 hours before the operation. You don't actually have to bridge thumb. Um, if you remember, we saw that this list. I'm just gonna jump back on. Major orthopedic surgery is a high risk for bleeding procedure. So if the standard or high risk of bleeding doses apply. So if you have, this is what you have to calculate the creatinine clearance because if they're clear, creatinine clearance is over 80. Then you can follow this 18 to 24 hour a mission rule. However, if the creatinine clearance is less, then you're going to have to stop. That does a lot earlier. And the reason for that is because it takes their kidneys that much longer to clear the anticoagulants from the system. So that little table at the bottom is a reference as to the standard is related to their risk of bleeding so standard or high risk of bleeding. So if we go back, standard risks Are these procedures here high risk? Are these procedures in red So based on those, you decide how long you need to admit, um, that do work full and it will be longer because orthopedic surgery, major orthopedic surgery is considered high risk. And if the creatinine clearance is and in these rockets, then you just follow how long you do it for? Um, if that person is creatinine clearance, by the way is is 15 or less, um, or 15 to 30 for the big Atran. They shouldn't be on those docks anyway, So if you find that the creatinine clearance is that low, you don't omit the don't work, and then start it again. You, um it the door and you actually stop on, get some advice from hematology on maybe even contact renal as to their creatinine clearance. Being that low, they shouldn't be on it. So that's that's all. Do X moving on to fragment. Um, I found three different guidelines. They all said patients on fondaparinux talk to him, which really helps me because that means I don't have to do all these calculations. I could just ask him what I need to do. But fragment, um is always based on their correct and clearance, which is a sweet do anyway, when we're doing all VT prophylaxis. So if that creatinine clearance is over 50. Just, um, it on the day of procedure. They can have it all the way up until the night before If the credit insurance is lower than, um, it for 48 hours rather than 24 hours. Um, and then again, if they corrected the clearance is less than 30 discussed with him. But usually you also admit for 40 it for 48 hours, and then you start again afterwards. Um, on. Then the last one is aspirin and clopidogrel. Krug a law, for example. These are for patients who've had an M. I drive, and, um, I a long time ago, and I've just been stuck on these anti platelets. So anti platelets. My consultant was telling me they don't even Button island. Um, they did. Shouldn't panic anybody in the emergency setting. It is absolutely not a not a contraindication to surgery. Um, in the elective setting. Ideally, you'd like to stop the aspirin 7 to 14 days beforehand. And you'd like to stop the clopidogrel 5 to 10 days beforehand. In most cases, depending on the risk in terms off the, um, I they might not even have to be restarted on them, so it's worth looking at their history. Have they just been left on these drugs after having ah, acute coronary syndrome a few years ago? And is it still relevant, or has, you know, things have things advanced on? Do they need to actually, rather than being on just aspirin, do they need to be on a different, um, anti platelets? So this is sort of an opportunity to review thumb. But absolutely do not worry if they come in on these on these drugs. Then we talk about post operative patients s. So that was preoperative. And what you do here is post operative again with warfarin, you commenced prophylactic dose, low molecular weight, hip runs or adult pouring off Rodman 6 to 8 hours post operatively. It's usually on the up note on. You can usually recommend their warfarin on the evening off the operation if they didn't have excessive bleeding. My consultant said she always likes to wait about two or three days POSTOP, just so that any bleeding risk can be very, very clearly assessed any sort of issues in terms of if they had an epidural or a spinal. Um, for example, if there was a trauma, dramatic lumbar puncture. Then you cleared that risk, and then you can start them on warfarin again. Um, you always bridge with Delta part in any way. So it's okay if they stay on your department for a little bit longer on, then when you start them on their warfarin, you start them on their usual dose, and you just keep monitoring that iron are as long as and and make sure that it's in range. So actually, again, I was scared of warfarin after doing the research I had to do for this, Um, teaching. I actually I'm not scared of warfarin anymore, so thank you guys. So next is our dough axe s. So if you have a low bleeding risk, the patient actually construct there. Doac straightaway was in six hours post operatively. They don't need to be bridged with low marks where it was low molecular weight, heparin. So, for example, these might be the people who had distal radius fractures, or they might have, you know, quite low wrist upward, a limb structures or very minor lower lumbar actors. Um, those those be less major. Therefore, they'll have a leslie bleeding risk, and you can actually start that back again. Um, if they have a standard risk of bleeding, so remember, we looked at that guideline then, um, you can use low molecular weight heparin in the evening and then start them the next day on that door on a prophylactic dose. And then if they have a high risk of bleeding, you start them on low molecular weight heparin that day. Um, with ah, um treatment dose on. Then you convert to the usual dose pack 2 to 3 days postoperatively again. That's all in this table, so you don't have to try and memorize it. It's all there for you. Um, if the person's on fragment restart the CT prophylaxis as as usual, as calculated, usually all be in the top. No telling you what to do. Um, and I put here a little note that the trust I work We normally give 28 days of UTI prophylaxis after unoperated that would significantly reduce mobility such as hip operations, major knee operations on actually an uncle operations where there'll be no weight bearing on that limb. We actually give it for six weeks rather than interest of four weeks and then last, but not least, is our anti platelets. Like I mentioned, anti platelets can actually be started, Um, when the anti coagulation that they're actually normally on. So if they're on low molecular weight heparin, for example, once that stopped, you can start there and to platelets again. Um, if there's a person who's got a high risk of em, I then you might want to start down to platelets pretty much straight away, especially if they're bleeding. Risk isn't actually that high, then it might be the safer thing to do. But again, please refer to a senior. Usually for, um, anti platelets. Cardio or stroke will be. You're a really good port, of course, just to find out what they think the right timing is for you. But because the patients are already going to be on some kind of E d prophylaxis is it's not as much of, ah anergic, uh, urgency as the rest of off these chemicals. Ah, beauty prophylaxis. So I also mentioned there were patients who had an increased VT risk that you may not have considered. So patients who are taking the combined or a contraceptive pill, um or Hey, Jodie, that contains Easter June in an elective sit setting. Ideally, you'd want them to stop four weeks prior because the Easter gyn content makes the VT of risk. Julia. But in an emergency setting, you might not have that luxury eso. Normally, what we do in that situation is we would actually prescribe et prophylaxis for 28 days after, even if the operation didn't in a person who wasn't taking the oral contraceptive pill would have meant they wouldn't have needed that long. So we're basically covering the fact that because they're they're in this hypercoagulable state and they've had surgery, they might have slightly reduced ability. We will cover them with a full 28 days. Postop, um, patient who patients were pregnant are also in a hypercoagulable states. Usually it's worth talking to hematology and gynecologic gynecology about this. It's worth just running. It passed them whether the operation is actually really necessary on how long they need to stay on it, for you wouldn't want to sort of take risks with a patient who is pregnant. It's always better to just check with the right specialty. Um, I've put him here. Patients who take regular Ansaids. Now The reason I put this here is because I saw a research recently, and the jury is still a little bit out that patients who regularly take and say so ibuprofen an approximate because of the Cox two inhibitor in they actually haven't increased VT risk. It makes them hypercoagulable. And that's really interesting. If you think about the fact that patients who also take regular insides haven't increased gastric also risk, which is at risk of bleeding. So not only do they have an increased risk of clots, they haven't increased risk of bleeding is one. And so it's really worth making sure in your history. You ask if a person takes regular ibuprofen or naproxen, asked them how long they've been taking it for, and use that in your considerations off. Whether you want the person to have a CT prophylaxis is in a different way. So, for example, if you weren't going to consider prophylactic no black away heparin then then actually do, it might be the safer thing to do with this patient or things like making sure that you don't prescribe them and say it's on that they are automatic result to reduce that risk of bleeding. And then lastly, patients wore a bees. Um, I basically patients were bees are in a hypercoagulable state anyway. They may have reduced ability. They may not, Um, on. They do require adjusted doses off prophylaxis. This is all in the V t assessment on, so just making sure you know their weight. You basically make sure that they've got enough, um, VT prophylaxis because being insufficiently medicated means that they are still at a high risk of clots. So that was a lot. Um, Andi, I hope. And that helps a little bit. We're going to do a few cases where we're just going to try and make this make a bit more sense. So do please join in on the chart because I'm looking at it with apple on. I would love for you to sort of play with a little bit, so case wouldn't This is more, uh, there is, um she's 78 years old on. She came in with a left neck of femur fracture. She has a background of a F. So she's on apixaban. Um, she has hypertension, osteoarthritis. She weighs 57 kg. She tripped over her low garden war and fell onto a side, so we know she doesn't have any other injuries on. So let's work through this case together. So, um, festival, uh, what would you do about the apixaban if we go back to preoperative? Would anyone like Teo tell me what we do about the APIXABAN? Because she's going to need a hip replacement, So try men whenever you want, but I work through a bit of the thinking with you, so if we go back to her, history will stop apixaban 48 hours before surgery. Brilliant. So why did you say 48? I was instead of 24. So here it says, um, the creatinine clearance, high risk of bleeding do two major trauma surgeon. Wonderful. Well done. But there is nothing in her history that suggests that she has, um, renal problems. So first things we do and thank you so much for answering. I really appreciate it because it gives me points toe sort of explain a few things. It wasn't It wasn't gonna be sitting anyway, so thank you on it. So, basically, first of all, there's nothing in the history that suggests you might have of any renal suggested we were on. We would use that if she had a creatinine clearance of, um, no, you're completely right. Wanna you? Yeah. Well done. You. You're completely right. It is above 80. Equal above Unequal to 80. She's right on his right. Okay, stop it. 48 hours beforehand. Well done. You're right. The reason honest said that and she's right. Is because the creatinine clearance is over 80. Because, let's just say she doesn't have any renal issues on the clearance is normal for her age on her bleeding risk is high because it's orthopedic surgery. That's a major, and it's considered high risk. So Yep, 48 hours. Well done. Um, in the low bleeding risk, it will be 18 to 24 hours. Fantastic. Welcome. Okay, so we've done her apixaban. We stopped it 48 hours in advance, and then she's gonna have her hip replacement after her hip replacement. What are we gonna do? No. One page on his right. So we've got a standard risk of bleeding. Um, so actually, I'd say you you made the right decision in terms of stopping the, um apixaban 48 hours in advance. but actually because you identified, she had a high risk of bleeding. Now, in here, it says, high risk of bleeding, prescribed, um, electrolyte heparin and then convert to Duac after 2 to 3 days. So that's probably what I do in this situation. But say she came out. It was a very straightforward procedure. She actually had minimal blood loss during the surgery. Then, yeah, after 24 hours, I think is absolutely reasonable. And I don't think anyone would argue with that. I think it would be really just that. Just acting on a very cautious side by doing the low molecular weight heparin and then converting to the apixaban afterwards just because low molecular weight heparin has a lower, slightly shorter half life. Um on. So with the dose pack, it's just a little bit less, um, a little bit more difficult to reverse them than the low molecular a happen. But yeah, I I would agree with you with for that, and I wouldn't argue with you for that one either. So well done. That's fantastic. So that was easy. Let's go to number to look at this is Fabio Huntsman, 39 year old male Hey, came in following a naughty, Obviously, he came off his motor bike, rides a motorbike. Look at him. Um, and he suffered a distal tibial fracture. He had a tonsillectomy as a child. The amount of things I have, I I don't know. He doesn't look like you weigh 105 kg is just believe me that he's very muscular. Um, is that anything in his history that might sort of make you think a little bit might make you want to just have a look at what you're going to be prescribing for him. Nice one. Really good. I was hoping someone would say that. Absolutely. So, uh, we've got a lovely and CEO Dizzy s, which is Would you look for any other signs of trauma? Absolutely. You would do a full trauma CT because these patients are at risk of see spine injuries. There a risk of bleeds on the brain. They might have rib fractures that might need monitoring. That could end up with him authorities that we don't identify. So absolutely, we'd look for other signs of injury. Other areas hit. The might have damaged was coming off his motor bike. Brilliant. Well, done anything else? Nothing about his weight. What? Thank you, Jody. So he's 105 kg. But is he obese? So, um, if you clot his BM I was part B m. I would probably be high because I am. I use this, He I said he's probably very mostly Let's assume he's very, very muscley. There will be a few things that this would impact. So first of all, because he's over 100 kg, he would have to have a five out of his prophylactic dose of Delta. Pourin would have to be 5000 units B d rather than 5000 units OD. So that's one practical aspect of his weight being over 100 kg. Secondly, if he is extremely muscley, then he'll have a higher amount of creatinin in his using these on when you calculate that against his weight on his age, it might show as a poor creatinine clearance, but actually his creatinine clearance might be absolutely fine because he's a young man. He doesn't have any civic, significant, um, issues in his history. Otherwise everything's fine. He might take a lot of supplements, for example, so these kinds of things you might want to consider when you're calculating the creatinine clearance and then, as a result, calculating how much he will have a a dose. So absolutely creatinine clearance, probably with him. He's young. Wouldn't worry about that as much. But the fact that he's over 100 kg, he's definitely gonna need BD doctor part. So what I would do in this situation is up until the night before his operation, he will receive prophylactic dose built up or in 5000 units, B D. He would have the adult apart and omitted on the day of the surgery on, then, after his surgery. If we go back to Post Operative, we would just do normal. And we would just restart on the evening off the operation with his what would have been his second dose off the B D 5000 units? Because you can restart 66 hours POSTOP on then because it was a distort tibial fracture. Can anybody tell me how long his post operative prophylaxis will be with daughter born fabulous. Thank you. Um, a lake. Um, So his, um, postoperative VT prophylaxis will actually be six weeks because he's probably likely to be nonweightbearing on that lower limb. Um, he will probably be very immobile for the next six weeks or so. So absolutely 4 to 6 weeks. I'd say six weeks because you'll be nonweightbearing through that lower limb if he was partial. Weightbearing four weeks is absolutely fine, but because he'll probably be nonweightbearing six weeks is probably the best way to go. I'll be completely honest with you. I don't even believe our patients finished all their courses. Um, they definitely told me that on. I do worry sometimes. Um, so there we go. So that was fantastic. You guys smashed that one. So just in summary preoperatively he would have 5000 units b d until the night before his surgery, omitting on the morning off his surgery, then six hours POSTOP. We start his second. What would have been his second dose off 5000 units? B D on. Then we would continue the 5000 units B D for a total of six weeks from the date of his operation. Last but not least, this is talk way and look at this guy is great. He's 87. He's lost his footing in a museum obviously, he was in a museum on. He fell onto his outstretched hand. He sustained a distal radio fracture. And I can't be asked doing the whole collies on. Not really staying, so let's not go there. Um, he has a background of an appendicitis to me 100 years ago. Um, he has osteoarthritis. He has hypertension. Type two diabetes. He had an MRI last year. So he's on aspirin and Lipitor girl. He has Parkinson's disease on a drug Ativan. Ocular degeneration. So basically, he's got this distort radial fracture. Um, is there anything you would like to highlight anything that you would like to consider? Sorry. Just giving you a moment to see that risk sheet and then back to his history. That's really, really good question, and that is exactly what I was hoping you'd hit. So basically a distance is asking. The conditions are off the loss of foot that yet Was it due to the Parkinson's, or was it something new? Excellent question on. Actually, I'm so glad you brought that up, because not only does it give us an indication of whether we need to actually check, so do a Parkinson's review. Maybe do a Parkinson's or federal, um, to make sure that he's on the correct medication for that. But actually, when it comes to his post operative anti coagulation, we need to actually reassess his bleed risk. So he had this MRI last year, and he's been on aspirin clopidogrel ever since. Then he's got Parkinson's disease, and now he's having falls. So has his Parkinson's disease worsen? Are his risk of falls even higher? We know that he's actually also got a related macular degeneration, which means his risk of fours is even higher because he's got Parkinson's disease so shuffling, gait, freezing and then on top of that he can't actually even see. So that is definitely something you need to take into account when you're making a decision as to whether to actually restart his aspirin Clopidogrel on. This is where your husband, your child Baskin, had has blood school come in because what you do is you do the child's child vascular for his B t risk. You do his house blood school, but then your husband school would also you can think about that couldn't context, but that he has an increased bleeding risk because of his falls asleep. Well, on then you can decide. Is it appropriate to start him on an anti platelets again? So well done. That was absolutely what I needed you to to hit on. So let's be a bit more technical this time. Um what preoperatively what would we do with his aspirin on clopidogrel? It's It's not a question. Yep. So we would stop for seven days if we had seven days before his or if if he had a stretching out the ultrasound if elected withhold for seven days. Excellent. Well done. Um, if it's we're going to do his operation tomorrow. You just stop it. Um, you just stop it a soon as you can. Um, he might have fallen this morning. Not taken established. That gives us an extra 24 hours of him not having taken it. It's not an absolute contraindication. To surgery is a well done, both of you and then post operative be taking into account fact that he had an MRI last year. He's 87. Yes, 87. Um, Andi. He has this increased falls risk taking all of that into account. This isn't a decision we'd ever have to make a junior doctor. So please, please don't ever feel like you're You're the one who has to decide, but it be useful to have a think of. What do you think someone more senior would do? Onda? I have. If you work in stroke or if you work in cardio, then they will absolutely go boom. Absolutely have to have the aspirin. In general, they will. You know that's going to be the top of that, their minds. Whereas if you're in orthopedic, if you're in orthogel react tricks or if you're in orthopedics on their risk of bleeding is higher. You would probably think on risk. Stratify. What's better for them? They're more likely to fall because of these two conditions, they're more likely to have a dangerous please. Where is Actually at 87. How much is the clopidogrel on? But, um, part up aspirin actually doing It's I think aspirin and clopidogrel are a lot better as preventative measures in people who are a bit younger. Whereas by this point he's you know, how does them I He's got absolutely chalker arteries, probably. Um and so you know, it will be people different people putting different hats on on actually making decision. So don't ever worry if you can't think of what the actual decision here is, because it is very, very individual to the senior. You're speaking to a time, um, on the reason I say this is because, um, when I was doing this teaching earlier today, one of my colleagues was like, Yeah, he's had in my last year. Absolutely. We have to start the aspirin clopidogrel, and you're off. The geriatric consultant went absolutely not because he will end up with coming in in a week's time with a subdural on. This is this is how it is in when you're deciding on people's care on it will depend on who the responsible clinician for that patient is at the time as to what they think the best thing to do for that patient is. So there we go. Um, so that was, um, anti coagulation. Peri operatively in form of Phoenix. Please, please, please fill in the feet back. I will put the pdf off those two tables on the website so that you guys can print it off. Um, I'm going to stick around here for about five minutes if you guys have any questions? Um, so just just, um, in the shot drop. Any questions? I'll be more than happy to try or if I anything I've said or give you an idea of what things are like, um, in the hospitals on a day to day basis. Okay. Assumed that was their questions. So thank you so much. Um, obviously drop us a message if you had any of burning questions after this on drying up for our next session, which is in two weeks' time, which is orthopedic emergencies. So thank you so much for joining me on. Thank you so much for helping me learn lots, because I learned to from just researching this.