Peri-operative management of ophthalmic patients taking antithrombotic therapy

Increasing number of patients presenting for ophthalmic surgery are using oral anti-coagulant and anti-platelet therapy. The current practice of discontinuing these drugs preoperatively because of a presumed increased risk of bleeding may not be evidence-based and could pose a significant risk to the patient's health. To provide an evidence-based review on the peri-operative management of ophthalmic patients who are taking anti-thrombotic therapy. In addition, we briefly discuss the underlying conditions that necessitate the use of these drugs as well as management of the operative field in anti-coagulated patients. A semi-systematic review of literature was performed. The databases searched included MEDLINE, EMBASE, database of abstracts of reviews of effects (DARE), Cochrane controlled trial register and Cochrane systematic reviews. In addition, the bibliographies of the included papers were also scanned for evidence. The published data suggests that aspirin did not appear to increase the risk of serious postoperative bleeding in any type of ophthalmic surgery. Topical, sub-tenon, peri-bulbar and retrobulbar anaesthesia appear to be safe in patients on anti-thrombotic (warfarin and aspirin) therapy. Warfarin does not increase the risk of significant bleeding in most types of ophthalmic surgery when the INR was within the therapeutic range. Current evidence supports the continued use of aspirin and with some exceptions, warfarin in the peri-operative period. The risk of thrombosis-related complications on disruption of anticoagulation may be higher than the risk of significant bleeding by continuing its use for most types of ophthalmic surgery.

Perioperative management of medications for psoriasis and psoriatic arthritis: a review for the dermasurgeon

BACKGROUND

Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery.

OBJECTIVES

The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures.

CONCLUSIONS

This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients

Growing evidence suggests that perioperative withdrawal of ASA for secondary stroke prevention increases thromboembolic risk without the associated benefit of decreased bleeding complications. ASA maintenance is acceptable in many procedures, including invasive ones. Many procedures, in particular ophthalmologic, dermatologic, and dental surgeries, also are safe while continuing oral AC. Warfarin has been continued successfully even in some surgeries that have high bleeding risk. When the risk is too high, temporary bridging therapy with LWMH is safe in many populations. Although the exact thromboembolic risks associated with temporary cessation of AP and AC are unknown and likely low, morbidity and mortality associated with thromboembolism are high. Further studies investigating the risks and benefits of maintaining AP and AC during procedures, particularly invasive ones, are needed. Meanwhile, it is critical that physicians understand the risks and benefits of perioperative AP and AC and the variety of procedures in which these agents can be safely continued.

A prospective study of the incidence of complications associated with dermatological surgery

BACKGROUND

Dermatological surgery is a relatively new and expanding subspecialty within dermatology. Little information is available about complications in this kind of surgery in the European setting.

OBJECTIVES

The aim of this study was to assess the incidence of anaesthetic, haemorrhagic and infectious complications in dermatological surgery and to highlight the factors associated with these complications.

METHODS

Data were collected prospectively over a 3-month period for all surgical procedures performed by a network of dermatologists (n = 84 dermatologists) in France, including the excision of all benign or malignant tumours but excluding sebaceous cysts and pyodermas. Information was collected regarding dermatologists, patients, procedures and complications.

RESULTS

A total of 3788 surgical procedures were available for review; 236 complications, mostly minor, occurred in a total of 213 surgical procedures (6%), bleeding being the most common (3%). Vaso-vagal syncope was the main anaesthetic complication (51 of 54). Infectious complications occurred in 79 patients (2%). Superficial suppuration accounted for 92% of surgical site infections. Only one patient had a systemic infection. Complications requiring additional antibiotic treatment or repeat surgery accounted for only 22 cases of 3788 (1%). No statistically significant correlation was found with the characteristics of the dermatologists, especially with respect to their training or amount of surgical experience. Similarly, no link could be established between complications and surgical conditions. Multivariate analysis showed that anaesthetic or haemorrhagic complications were independent factors for infectious complications. Sex, administration of an anticoagulant or immunosuppressant, type of procedure performed and duration exceeding 24 min were independent factors for haemorrhagic complications.

CONCLUSIONS

This study shows a low rate of complications associated with dermatological surgery performed by dermatologists under local anaesthesia on an outpatient basis.

Withdrawal of Warfarin prior to a Surgical Procedure: Time to Follow the Guidelines?

BACKGROUND AND OBJECTIVE

Patients with cardiogenic sources of embolism may be at increased risk of cerebral infarction when anticoagulation therapy is suspended for surgical procedures. The purpose of this study was to determine frequency of cardioembolic cerebral infarction during periprocedural warfarin withdrawal.

METHODS

Retrospective analysis of prospective cerebral infarction registry data from two tertiary medical centers.

RESULTS

Over a 12-month period, 14 cases of cardioembolic cerebral infarction occurring during the period of warfarin withdrawal for a medical procedure were observed, accounting for 7.1% of the 197 cardioembolic cerebral infarctions encountered. Across all patients, cerebral infarctions developed an average of 5.4 days after the last dose of warfarin (range 3-8). Among the 14 patients (8 males and 6 females) with warfarin cessation-related infarcts, age ranged from 54 to 91 years. Each had been on chronic anticoagulation with warfarin for more than 1 year. Retrospective analysis suggested that all these cerebral infarctions had been potentially preventable. In each case, either the planned procedure did not require discontinuation of warfarin or, when withdrawal was required, no bridging, parenteral anticoagulation was provided to lessen the risk during the warfarin-free period.

CONCLUSION

Patients at high risk of cardioembolic cerebral infarction may benefit from more intensive management strategies to reduce cerebral infarction risk during periprocedural periods.

Controversies in perioperative management of blood thinners in dermatologic surgery: continue or discontinue?

BACKGROUND

The use of blood thinners has increased dramatically in recent years among the general, and especially among the elderly, population. When these patients need to undergo cutaneous surgery, the surgeon encounters the obvious problem of whether to stop these medications before surgery.

OBJECTIVE

The objective was to evaluate the risks and benefits associated with the continuation of blood thinners perioperatively in cutaneous and Mohs micrographic surgery.

METHODS

The study comprises two parts: a search of the literature in English that examined articles that related to the perioperative use of blood thinners in dermatologic surgery and a presentation of data of continuous warfarin therapy in patients who underwent Mohs surgery in our practice.

RESULTS

A total of 15 articles were published in the literature until October 2003. One article showed an increase in complications in patients treated with warfarin, but not with aspirin. All other articles showed no increase in complications during the perioperative period. Data from our practice showed that of a total of 2790 patients, 68 were operated on while taking warfarin (2.4%). Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients.

CONCLUSION

Continuous treatment with blood thinners perioperatively in patients undergoing Mohs and cutaneous surgery is not associated with an increase in surgical complications. Discontinuation of these medications may increase the risk of cerebral and cardiovascular complications.

Cutaneous surgery in the elderly: ensuring comfort and safety

Increasingly, cutaneous surgeons are asked to treat cancers and the visible signs of aging in extremely elderly patients. While many elderly patients have functional status similar to that of younger patients, some older patients may have co-morbities and special needs that must be monitored and accommodated by the skin surgeon. A rational approach to surgery can increase the comfort and safety of surgery in such patients. Overall, cutaneous surgery is well-tolerated in even the oldest patients.

Preoperative monitoring of warfarin in cutaneous surgery

BACKGROUND

We report a patient who developed postoperative bleeding as a result of inadvertent excessive warfarin intake. We subsequently introduced a policy of checking the international normalization ratio (INR) 24 h before cutaneous surgery for all patients on warfarin.

OBJECTIVES

To review the perioperative INR and outcome of all patients on warfarin who had cutaneous surgery from January 1999 to June 2002 at the Department of Dermatology, Sunderland Royal Hospital.

METHODS

A retrospective review was undertaken from patients' medical records.

RESULTS

Sixty-eight patients (1.84% of total) underwent 85 skin procedures comprising 33 excisions, 16 punch biopsies, 15 curettages, 13 diagnostic biopsies, five shave biopsies, two Mohs micrographic surgical excisions and one delayed reconstruction. Repairs included 50 direct closures, five secondary intention healing, seven local flaps, two full-thickness skin grafts and 20 by electrocautery. Forty-five surgical procedures were undertaken with the INR checked on the day of surgery, 37 procedures within 24 h, and three within 2 days. The preoperative INR ranged from 1.1 to 3.4, median 2.5. There was no excess intraoperative or postoperative bleeding or haematoma for all patients.

CONCLUSIONS

Our experience supports the continued and safe use of warfarin for a wide variety of cutaneous surgical procedures with a preoperative INR of < 3.5. We recommend a routine INR before the procedure, preferably within 24 h.

Outcome of aspirin use during excision of cutaneous lesions

The perioperative course of 253 patients undergoing excision of cutaneous and subcutaneous lesions by the same surgeon was evaluated, comparing patients using aspirin and those not using aspirin. Intraoperative methods of obtaining hemostasis and the incidence of postoperative complications were evaluated. Suture ligatures were used more frequently in the group using aspirin, but there was no statistical difference in the use of electrocautery. There was also no difference in the incidence of wound dehiscence, erythema, or hematoma. The outcome of excision of cutaneous and subcutaneous lesions under local anesthesia is not affected by patients using aspirin.

Implantation of pacemakers and implantable cardioverter defibrillators in orally anticoagulated patients

The safety of pacemaker and defibrillator implantations in orally anticoagulated patients using standard techniques has not been thoroughly evaluated. This article describes a prospectively collected experience in such patients. Patients presenting for device implantation who were treated with warfarin were allowed to continue therapy provided that the INR was < 3.5. Implantations involved cannulation of the left axillary vein. Except for defibrillator leads, 7 Fr introducers were used, and all were leads actively fixated. The study included 47 patients who underwent implantation of permanent pacemakers (n = 39), defibrillators (n = 5), or biventricular pacemakers (n = 3). The mean INR was 2.3. The primary indication for anticoagulation was a mechanical cardiac prosthesis in 11 (24%) patients. Atrial fibrillation was present in 33 patients. There were no instances of major bleeding or hematomas requiring evacuation. One patient had a small soft hematoma, which resolved spontaneously. At 6 weeks, all patients had well-healed scars with satisfactory pacing and sensing thresholds. In experienced centers, patients requiring treatment with warfarin may undergo implantation of pacemakers or defibrillators with minimal risk despite continuation of anticoagulation.

DVT prophylaxis and anticoagulation in the surgical patient

One of the most common postoperative complications is venous thromboembolism, a term encompassing deep vein thrombosis and pulmonary embolism. This article reviews the epidemiology, natural history, difficulties in diagnosis, and strategies for the prevention of postoperative venous thromboembolism. We thoroughly review the currently available methods for thromboprophylaxis including: early ambulation, elastic compression stockings, pneumatic compression devices, inferior vena cava filters, and a variety of pharmacologic agents such as unfractionated heparin, warfarin, aspirin, low molecular weight heparin, and pentasaccharides. Finally, we review the perioperative management of patients on long-term oral anticoagulation.

Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy

BACKGROUND

Antithrombotic medications may increase perioperative bleeding during cutaneous surgery. Whether to discontinue these medications before surgery is controversial.

OBJECTIVE

To evaluate the available evidence in order to generate preliminary guidelines regarding the perioperative use of antithrombotics.

METHODS

Presentation of two cases of adverse events after preoperative discontinuation of antithrombotics, review of current anticoagulant and antiplatelet drugs, and review of the literature concerning perioperative antithrombotics in cutaneous surgery.

RESULTS

Perioperative withholding of antithrombotics in cutaneous surgery may be associated with serious adverse vascular events. Continuing antithrombotics in these circumstances does not appear to significantly increase bleeding complications. The complexity of available antithrombotics makes case-by-case determinations regarding their use difficult.

CONCLUSION

Cutaneous surgeons should strongly consider perioperative continuation of patients' antithrombotic drugs. The final determination should be made by the surgeon after evaluation of the circumstances and, if necessary, consultation with other experts.

Perioperative management of anticoagulants and platelet inhibitors for cutaneous surgery: a survey of current practice

BACKGROUND

Perioperative management of therapy with anticoagulants or platelet inhibitors for patients having cutaneous surgery presents dilemmas for dermatologic surgeons.

OBJECTIVE

To outline the current spectrum of practice for perioperative management.

METHODS

Questionnaires were mailed to 504 dermatologic surgeons. Data included use of warfarin, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) perioperatively and involvement of other physicians in making management decisions.

RESULTS

Of the responding physicians, 83% routinely ask primary physicians or cardiologists for recommendations about perioperative management, 80% discontinue warfarin therapy perioperatively at least some of the time, 26% always discontinue aspirin therapy, 38% manage aspirin and NSAIDs in the same manner, and 53% withhold therapy with NSAIDs for less time than with aspirin.

CONCLUSION

Dermatologic surgeons use various perioperative management strategies. Despite no published evidence of increased hemorrhagic risk with anticoagulant or platelet inhibitor therapy during cutaneous surgery, many physicians discontinue therapy perioperatively.

The management of anticoagulation before and after procedures

Patients maintained on warfarin for atrial fibrillation, mechanical heart valves, or deep venous thrombosis may occasionally need to stop their anticoagulation during invasive procedures. This article reviews the literature on bleeding risks of certain procedures, thrombosis risks of stopping anticoagulation, and heparin and warfarin pharmacokinetics. Recommendations regarding how to manage anticoagulated patients are discussed.

Cutaneous surgery in patients receiving warfarin therapy

BACKGROUND

Anticoagulant treatment with warfarin is an essential therapy in patients with prosthetic heart valves and atrial fibrillation to prevent thromboembolisms. The question whether to stop warfarin treatment in patients undergoing cutaneous surgery is debatable.

OBJECTIVE

To evaluate the outcome of surgery in patients that were treated with warfarin and underwent excisional and Mohs surgeries.

METHODS

Warfarin therapy was continued in all patients that underwent excisional and Mohs surgery in our practice from November 1999 to November 2000. Perioperative complications such as bleeding and cosmetic outcome are evaluated.

RESULTS

A total of 560 patients underwent Mohs surgery and 530 patients underwent excisional surgery. Sixteen patients (1.5%) were treated with coumadin with international normalized ratio (INR) values within the therapeutic values. Seventy-seven patients that underwent surgery on the same days as the warfarin-treated patients served as the control group. Intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. All wounds healed without any complication, including full-thickness grafts.

CONCLUSION

Coumadin treatment should be continued in patients undergoing cutaneous surgery. This will decrease the risk of thromboembolic events.

Postoperative stroke after stopping warfarin for cutaneous surgery

BACKGROUND

Two patients undergoing cutaneous surgery had thromboembolic strokes within 1 week after surgery. Both patients had been taking warfarin for prevention of thromboembolism and warfarin was stopped 3-7 days prior to surgery.

OBJECTIVE

To examine the rationale and problems associated with preoperative warfarin discontinuation.

METHODS

Review of the medical literature.

RESULTS

When warfarin is stopped prior to surgery and restarted soon after surgery, the patient is at increased risk for thromboembolism. Although it is commonly believed that continuing warfarin during surgery is associated with an increased bleeding risk, for cutaneous surgery, this risk is extremely low and can be easily managed.

CONCLUSION

Warfarin should not be discontinued prior to cutaneous surgery because of the risk of thromboembolic stroke.

Elder care and the dermatologic surgeon

BACKGROUND

The elderly are an increasing percentage of the population and dermatologic surgeons will be caring for more senior citizens.

OBJECTIVE

Understanding issues in geriatric care will help both surgeons and patients have productive and rewarding encounters.

METHODS

Approaches to the care of elders are detailed in this article. Surgical tips for the senior patient are prescribed.

RESULTS

Older patients need more time and may need special assistance. Multiplicity of disease increases with age. A third-party interview can be helpful in gathering information. The elderly have sensory loss and benefit from extra attention, follow-up telephone calls, and therapeutic touch. Written handouts and instructions printed in large type are excellent. Dermatologic care should be kept as simple as possible with surgical closures designed to require minimal attention. Be cognizant of the social services available for the elderly and watch for dermatologic signs of internal disease. A skin care program for the elderly is helpful and cosmetic procedures are of interest to seniors.

CONCLUSIONS

Dermatologic surgeons can provide excellent care to elders. An understanding of gerontologic issues and surgical tips can help the dermatologic surgeon care for the older patient.

Dermatology therapy update

New treatments for skin disease continue to evolve. This article summarizes recent advances in dermatologic therapy and suggests various alternative approaches for situations in which more conventional modalities are unavailable, ineffective, or contraindicated.

Outpatient pacemaker procedures in orally anticoagulated patients

Reexamination of surgical practices in the present era of cost containment has led to increased outpatient procedures including pacemaker surgery. While the safety and economic benefits of outpatient pacemaker surgery in nonanticoagulated patients is well documented, results of pacemaker operations in patients maintained on coumadin for thromboembolic prophylaxis have not been evaluated. In patients where complications with pacemaker surgery appeared successive, we have established a low incidence of complications. Recently, we extended this approach to the outpatient setting; this report retrospectively reviews our 4-year experience. During the study period, 150 patients underwent outpatient pacemaker procedures, including 37 patients receiving oral warfarin. There was no difference in the incidence of wound related and wound unrelated complications between patients receiving warfarin and the nonanticoagulated cohort. In addition, no wound hematomas, blood transfusions, or clinically significant bleeding episodes were noted among warfarin recipients. We conclude that pacemaker surgery in patients receiving oral anticoagulation is safe and feasible. The use of the cephalic cutdown technique avoiding blind subclavian punctures, meticulous attention to pocket hemostasis, and the use of small caliber unipolar positive fixation leads appears warranted in this selected group of patients at high risk for perioperative bleeding.