Preoperative evaluation: A time-saving algorithm

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Applied Evidence

Preoperative evaluation: A time-saving algorithm

J Fam Pract. 2016 October;65(10):702-704,706-710

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References

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Anticoagulant medications

Whether patients quit smoking less than or more than 2 months before surgery is less important than that they quit.

Vitamin K antagonists (warfarin). Discontinue warfarin 5 days prior to the procedure. The half-life is approximately 40 hours, requiring at least 5 days for the anticoagulant effect to be eliminated from the body.²³ Use of bridging therapy with regular- or low-molecular weight heparin remains controversial due to increased surgical bleeding risk without evidence of a decrease in cardiovascular events.²⁴The patient’s risks of stroke and venous thromboembolism should be taken into account when deciding whether to use bridging therapy or not.
Factor Xa inhibitor. Management of factor Xa inhibitors (rivaroxaban, apixaban) depends on the bleeding risk of the surgery and the patient’s renal function.^24,25 For instance, a patient undergoing cataract surgery (low risk) needs a shorter cessation time than a patient undergoing hip arthroplasty (high risk). Discontinuation times are listed in TABLE 3.²⁴
Direct thrombin inhibitor. Management of direct thrombin inhibitors (dabigatran) is also dependent on surgical bleeding risk and renal function (TABLE 3).^23,24
Aspirin, clopidogrel, ticlopidine, prasugrel. All should be stopped 7 to 10 days prior to surgery to allow new platelet growth. Low-dose aspirin for secondary prevention of cardiovascular disease or primary prevention in a high-risk patient can be continued through surgery.²³

Other

Corticosteroids. Recent evidence suggests that stress-dose steroids are not needed to prevent adrenal insufficiency in patients taking corticosteroids chronically.²⁶ These patients should continue maintenance therapy at regular dosing.^26,27Stress dosing of corticosteroids is only required when a patient has signs of adrenal insufficiency.²⁶
Statins. Statin medications should be continued on the day of surgery.²
Nonsteroidal anti-inflammatory drugs. NSAIDs should be stopped 5 days prior to surgery to reverse antiplatelet effects.²³

CORRESPONDENCE
CDR Michael J. Arnold, Naval Hospital, 2080 Child Street, Jacksonville, FL 32214; michael.j.arnold4.mil@mail.mil.

ACKNOWLEDGEMENT
The authors thank CDR Kristian Sanchack and LCDR Dustin Smith for their assistance with this manuscript.