Perioperative anticoagulant management 1. Patients who are receiving warfarin anticoagulation and are proposed for elective surgery should discontinue warfarin 5 days before surgery and monitor the International Normalized Ratio (INR) again 1 day before surgery. Patients with elevated INR should be given oral vitamin K (1.0-2.5 mg) promptly to avoid intraoperative administration of blood products or postponement of surgery.
2. For patients with high risk of thromboembolism, after preoperative discontinuation of warfarin, bridging anticoagulation therapy with therapeutic dose of low molecular heparin is preferred as a temporary substitute for warfarin; for medium risk patients, therapeutic dose of low molecular heparin or normal heparin or prophylactic dose of low molecular heparin is recommended; for low risk patients, only prophylactic dose of low molecular heparin is given or no bridging therapy is given.
3. Bridging anticoagulation should not be given to patients at intermediate risk of thromboembolism who are undergoing procedures with high bleeding risk.
4. Newer anticoagulants such as dabigatranate and rivaroxaban have a short half-life and can be discontinued 24 h before surgery, but the half-life of dabigatranate is prolonged in renal impairment, and the time to discontinue dabigatranate in patients with renal impairment should be extended.
5. The time to resume anticoagulant drugs depends on the bleeding risk of surgery. In general, dosing can be resumed 24h after surgery for low bleeding risk, while it takes 48-72h to resume dosing after surgery for high bleeding risk.
6. In case of intralesional anesthesia and high bleeding risk surgery the use of relevant medications needs to be discussed with the anesthesiologist and surgeon. Hemorrhage risk assessment High risk.
Intracranial or spinal cord surgery, major vascular surgery (abdominal aortic aneurysm, aortofemoral bypass), major urological surgery (prostatectomy and cystectomy), major orthopedic surgery (hip/knee replacement), lobectomy, gastrointestinal surgery, permanent pacemaker or defibrillator, elective surgery (major colon polyp removal).
Intermediate risk.
Other abdominal surgery, other thoracic surgery, other orthopaedic surgery, other vascular surgery, elective small polypectomy, prostate puncture, neck puncture.
Low-risk.
Laparoscopic cholecystectomy, laparoscopic hernia repair, non-cataract ophthalmic surgery, coronary angiography, gastroscopy or enteroscopy, thoracentesis, bone puncture, etc.
Very low.
Tooth extraction, skin biopsy, cataract surgery.
This article is authorized by Dr. Jun Qu.