Date:
Patient: [Patient Name], [Age], [Medical Record Number]
Attending: [Physician Name]
I. Preoperative Assessment
Reason for Surgery: Briefly describe the planned surgery.
Antithrombotic Medications:
List all current antithrombotic medications (e.g., warfarin, heparin, clopidogrel, direct oral anticoagulants [DOACs]).
Document the indication for each medication (e.g., atrial fibrillation, deep vein thrombosis [DVT], pulmonary embolism [PE]).
Bleeding Risk: Assess the patient’s bleeding risk based on the type of surgery, underlying medical conditions, and presence of additional risk factors (e.g., recent bleeding, platelet count).
II. Consultation with Anesthesia
Collaborate with the anesthesia team to determine the optimal timing for holding or restarting antithrombotic therapy.
Consider risk-benefit analysis of bleeding vs. thrombotic complications based on surgery type and patient-specific factors.
III. Specific Antithrombotic Management Plan
Warfarin:
Holding: Ideally stop warfarin 3-5 days before surgery, with bridging therapy using low-molecular-weight heparin (LMWH) if necessary to maintain anticoagulation.
Reversal: Consider bridging with fresh frozen plasma (FFP) or vitamin K if surgery cannot be delayed and INR is supratherapeutic.
Heparin:
Holding: Stop unfractionated heparin (UFH) 4-6 hours before surgery depending on the dose.
LMWH: Holding duration depends on the specific LMWH agent and planned surgical procedure.
Antiplatelet Agents:
Aspirin: Typically stopped 7-10 days before surgery.
P2Y12 inhibitors (clopidogrel, ticagrelor): Holding duration varies depending on the agent and surgery type. Consider risk of stent thrombosis if recently placed.
DOACs:
Specific holding guidelines vary depending on the agent and planned surgery. Refer to the latest recommendations for each medication.
IV. Bridge Therapy (if indicated)
LMWH is the most common bridging agent during the perioperative period.
Document the specific LMWH chosen, dose, and duration of administration.
V. Postoperative Management
Resume antithrombotic therapy as tolerated based on bleeding risk and surgical recovery.
Monitor for signs of bleeding or thromboembolic complications.
VI. Discharge Instructions
Provide clear instructions regarding restarting antithrombotic medications and any follow-up appointments.
Advise the patient to report any signs of bleeding or unusual symptoms.
VII. Notes
Document any additional information relevant to the patient’s perioperative antithrombotic management, such as:
Consultations with hematology or other specialists.
Specific laboratory monitoring (e.g., INR, platelet count).
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. The specific management of antithrombotic therapy in the perioperative period can vary depending on individual patient factors and should be determined in consultation with a qualified healthcare professional.