Concerns regarding interrupting chronic anticoagulation involve the increased risk of thromboembolism and the theoretical risk of a rebound hypercoagulable effect.8 Patients prescribed warfarin have been found to unintentionally discontinue this medication after outpatient surgery at more than 1.5 times the rate of the general population.9
A systematic review of 9 published studies looking specifically at elective hand and wrist surgeries demonstrated no significant increase in perioperative bleeding risk with the continuation of anticoagulation and antiplatelet medications.10 Sardenberg and colleagues reviewed 7 studies in which 410 hand and wrist surgeries were performed in patients prescribed warfarin or aspirin and clopidogrel. These patients had a 0.7% serious complication rate, requiring surgical treatment only in patients having complex wrist surgeries (wrist arthrodesis with tenosynovectomy, resection of the distal ulna with tenosynovectomy and tendon transfer, and proximal row carpectomy).11 Bogunovic and colleagues compared 50 hand and wrist patients who were on uninterrupted warfarin with those who were not. They required patients to have an international normalized ratio (INR) < 3.5, but 1 patient required a return to the operating room for a bleeding complication due to an INR of 5.4 on postoperative day 4. They caution vigilant monitoring of INR.12
These and our study are consistent with other disciplines, such as facial plastic surgery, dermatology, and ophthalmology, which do not support routine suspension of anticoagulants.13-16 A review of 30 cutaneous surgery studies involving > 14,000 patients recommended meticulous hemostasis over cessation of blood thinners.15 The University of Massachusetts Dermatology Clinic found a 40 times higher rate of bleeding complications in patients on clopidogrel and warfarin but still recommended continuation of these medications to avoid thrombotic events.16
Limitations
This study is a retrospective chart review and limited by what is already documented in the electronic health record. We can verify that the patients were given instructions to continue their medications up to the day of surgery but cannot be certain whether the instructions were followed. No control group was told to hold their anticoagulants for the same surgery. Once we decided on a protocol, we applied it to all patients. The study approval was for the specific time frame when the protocol was in place.
Our study was designed for elective hand cases because those surgeries can be anticipated, predicted, and patients can be given instructions during the preoperative appointments. We did incidentally find several nonelective hand cases (traumas, infections, and cancers) during the review of patients taking prescription blood thinners that had to be expedited to the operating room. Based on morbidity data during that time period, there were no additional postoperative hand surgery bleeding complications that had to return to the operating room. Future studies are indicated, but we believe our protocol can be applied to urgent and emergent hand surgeries as well as elective cases.
Conclusions
Our study supports continuing prescription anticoagulant and antiplatelet medications during the perioperative period for elective hand surgery. We found this is a safe practice in our veteran population with an acceptably low local bleeding complication rate.
Acknowledgments
This manuscript is the result of work supported with the resources and the use of facilities at the North Florida/South Georgia Veterans Health System in Gainesville, Florida.