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When to stop anticoagulants before surgery?

Asked by Suresh 

In the pre-operative period, various anticoagulants may be used. The anticoagulants must be stopped following hours/days prior to the surgery:

1. Unfractionated heparin: 6 hours 

2. Low molecular weight heparin (LMWH): like Enoxaparin 
  • Prophylactic dose: 12 hours
  • Treatment dose: 24 hours 
3. Xa inhibitors: Like Rivoroxaban, Apixaban, Fondaparinux
  • Atleast 24 hours
4. IIa inhibitors: Dabigatran
  • CrCl >/= 50 ml/min: 1-2 days
  • CrCl <50 ml/min: 3-5 days
5. Warfarin: 5 days

6. Aspirin and Clopidogrel: 7 days

7. Stents:
  • Bare metal stents: Delay surgery for 6 weeks
  • Drug eluting stents: Delay surgery for 6-12 months; otherwise consider continuing agents 

1. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64-101 and White RH, McKittrick T, Hutchinson R, Twitchell J. Temporary discontinuation of warfarin therapy: changes in the international normalized ratio. Ann Intern Med. 1995;122(1):40-42.
2. Yeung LYY, Sarani B, Weinberg JA, McBeth PB, May AK. Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation. Trauma Surg Acute Care Open. 2016 Jul 13;1(1):e000022. doi: 10.1136/tsaco-2016-000022. PMID: 29767644; PMCID: PMC5891708.