Resident Readiness General Surgery (64 page)

TIPS TO REMEMBER

Elective cases should be delayed in the following situations:

VTE within the last 3 months

Bare metal stent placement within the last 6 weeks

Drug-eluting stent placement within the last year

Stroke or TIA in the past month in the setting of AF or a mechanical valve

The decision to bridge begins by categorizing the patient into high-, moderate-, or low-risk groups for a thromboembolic event. Patients in the high or moderate groups should generally receive bridging therapy.

The ultimate decision of whether or not to bridge should include a discussion between the surgeon, patient, and the patient’s cardiologist, hematologist, and/or primary care physician.

In general, warfarin should be held 5 days prior to the operation.

When bridging is employed, it should be started 3 days prior to the operation.

IVUH should be held for a minimum of 4 hours before the case. If a patient is receiving twice-daily LMWH for bridging, the last dose should be given 24 hours prior to surgery. If daily dosing is used, then the last dose should be given 24 hours prior to surgery at 50% of the regular dose.

Bridging should generally be resumed within 24 to 72 hours post surgery, after there is evidence of adequate hemostasis.

Warfarin can generally be resumed on postoperative day 1 as it will not have an effect for a few days.

In general, Plavix should be held 5 to 7 days prior to surgery.