Aspirin

1. •Where possible Aspirin should be stopped for all procedures 1 week prior to major surgery. However ...
   

2. •There are few operations which need to be postponed because of low dose Aspirin
   

3. •Where there is a high risk for CVA, TIA or other circulatory thrombosis it should be continued if the risk is acceptable, or an alternative sought
   

4. •Aspirin should not be stopped in the presence of a coronary stent
   

Consult surgeon for specific advice

                                      

Plavix

1. •Where possible Plavix should be stopped for all procedures 2 weeks prior to major surgery unless there is a clear indication for its continued use e.g. coronary stent. In general, epidural catheters are contra-indicated in the presence of Plavix.
   

2. •In the presence of a coronary stent, it may be appropriate to change to Aspirin. In the presence of a coronary stent, some form of antiplatelet treatment must be continue (see below).
   

Coronary Stents

General guidelines for coronary stents

1. •In the presence of a coronary stent, it may be appropriate to change to Aspirin. In the presence of a coronary stent, some form of antiplatelet treatment must be continue (see below).
   

2. •Coronary stent inserted within 12 months CANNOT be considered to have re-epithelialised and must either continue Plavix or be admitted for appropriate alternative anticoagulant/anti-platelet therapy. (e.g. therapeutic doses of Clexane or short-acting intravenous GPIIb/IIIa inhibitor). This is best done in consultation with the cardiologists. Most viable alternatives also rule out the use of an epidural so the surgeon and anaesthetic will need to decide on an alternative such as an extrapleural/para-vertebral infusion.
   

3. •Covered drug-eluting coronary stents more than 12 months CANNOT be considered to have re-epithelialised and should either continue Plavix or be admitted for alternative alternative anticoagulation/anti-platelet therapy in consultation with the cardiologists
   

4. •Bare metal stent more than 12 months may have re-epithelialised and, if the cardiologist is in agreement, Plavix can be stopped. Aspirin may be continued.
   

Consult surgeon for specific advice

Warfarin

•For atrial fibrillation – stop warfarin 4 days prior and maintain on Enoxoparin 1.0mg per kg. (i.e double standard prophylactic dose). If there is a reasonable time period before surgery is required request a cardiology opinion. If on echocardiogram the left atrium < 4cm warfarin can sometimes be stopped.

•For prosthetic mitral valve – admit 3 days prior, maintain on iv Heparin and monitor to maintain APPT at 2-3 times normal. Stop Heparin 6 hours prior to surgery.

•For aortic valve (mechanical) - admit 3 days prior, maintain on iv Heparin and monitor to maintain APPT at 2-3 times normal. Stop Heparin 6 hours prior to surgery.

•For aortic tissue valve – generally these will not be on Warfarin unless concomitant AF. Continue Aspirin.