CHEST-2012 Perioperative Management Flashcards
When should you stop VKA prior to surgery (if required)?
Stop 5 days prior to surgery (not less)
In patients who require temporary interruption
of a VKA before surgery, we recommend
stopping VKAs approximately 5 days
before surgery instead of stopping VKAs a
shorter time before surgery (Grade 1C)
When to resume VKA after surgery?
Resume 12-24 hours after and if hemostasis achieved
In patients who require temporary interruption
of a VKA before surgery, we recommend
resuming VKAs approximately 12 to 24 h
after surgery (evening of or next morning) and
when there is adequate hemostasis instead of
later resumption of VKAs (Grade 2C)
Which patients should be bridged if interrupting VKA?
Patients with mechanical heart valve, Afib, or VTE
AND high-risk for thromboembolism
In patients with a mechanical heart valve,
atrial fi brillation, or VTE at high risk for thromboembolism,
we suggest bridging anticoagulation
instead of no bridging during interruption
of VKA therapy (Grade 2C) .
Should you bridge in patients with mechanical heart valve, Afib, or VTE AND low risk for thromboembolism?
No bridging required.
In patients with a mechanical heart valve, atrial
fi brillation, or VTE at low risk for thromboembolism,
we suggest no-bridging instead of
bridging anticoagulation during interruption of
VKA therapy (Grade 2C)
Recommendations for patients on VKA and having minor dental procedure?
Continue VKA and use oral prohemostatic agent,
or stop VKA 2-3 days prior
In patients who require a minor dental procedure,
we suggest continuing VKAs with coadministration
of an oral prohemostatic agent or
stopping VKAs 2 to 3 days before the procedure
instead of alternative strategies (Grade 2C) .
Recommendation for patient on ASA for CVD prevention and having minor dental/dermatologic/cataract surgery?
Continue ASA (no need to stop 7-10 days prior)
In patients who are receiving ASA for the
secondary prevention of cardiovascular disease
and are having minor dental or dermatologic
procedures or cataract surgery, we suggest continuing
ASA around the time of the procedure
instead of stopping ASA 7 to 10 days before the
procedure (Grade 2C)
Recommendation for patient on ASA for mod/high risk for CVD event and need noncardiac surgery?
Continue ASA
In patients at moderate to high risk for
cardiovascular events who are receiving ASA
therapy and require noncardiac surgery, we
suggest continuing ASA around the time of surgery
instead of stopping ASA 7 to 10 days before
surgery (Grade 2C) .
Recommendation for patient on ASA and require CABG surgery? What about those on dual antiplatelet therapy with clopidogrel/prasugrel?
Continue ASA, hold clopidogrel/prasugrel 5 days prior
In patients who are receiving ASA and
require CABG surgery, we suggest continuing ASA around the time of surgery instead of stopping
ASA 7 to 10 days before surgery (Grade 2C) .
In patients who are receiving dual antiplatelet
drug therapy and require CABG surgery, we
suggest continuing ASA around the time of surgery
and stopping clopidogrel/prasugrel 5 days
before surgery instead of continuing dual antiplatelet
therapy around the time of surgery
(Grade 2C)
When should a patient with a coronary stent and on dual antiplatelet therapy have surgery?
Defer surgery for at least 6 weeks after placement of bare stent, or after 6 months for drug-eluting stent if possible
If surgery is required within these periods, then just continue dual antiplatelets instead of holding
In patients with a coronary stent who are
receiving dual antiplatelet therapy and require
surgery, we recommend deferring surgery for
at least 6 weeks after placement of a bare-metal
stent and for at least 6 months after placement of
a drug-eluting stent instead of undertaking surgery
within these time periods (Grade 1C) . In
patients who require surgery within 6 weeks of
placement of a bare-metal stent or within 6 months
of placement of a drug-eluting stent, we suggest
continuing dual antiplatelet therapy around the
time of surgery instead of stopping dual antiplatelet
therapy 7 to 10 days before surgery (Grade 2C) .
When should therapeutic dose UFH be stopped prior to surgery?
Hold 4-6 hours prior to surgery (not less)
In patients who are receiving bridging anticoagulation
with therapeutic-dose IV UFH, we suggest stopping UFH 4 to 6 h before surgery
instead of closer to surgery (Grade 2C) .
When should you resume therapeutic dose LMWH after a high-bleed risk surgery? After a low-bleed risk surgery?
Resume 48-72 hours after high-bleed risk surgery,
24 hours after low-bleed risk surgery
In patients who are receiving bridging anticoagulation
with therapeutic-dose SC LMWH
and are undergoing high-bleeding-risk surgery,
we suggest resuming therapeutic-dose LMWH
48 to 72 h after surgery instead of resuming
LMWH within 24 h after surgery (Grade 2C) . In
patients who are receiving bridging anticoagulation
with therapeutic-dose SC LMWH and are
undergoing non-high-bleeding-risk surgery, we
suggest resuming therapeutic-dose LMWH
approximately 24 h after surgery instead of
resuming LMWH more than 24 h after surgery.
