From the Guidelines
The recommended duration for withholding anticoagulants post-orthopedic surgery is at least 24 hours for most patients, with specific guidance provided in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline 1. When considering the management of anticoagulants in the perioperative period, it's crucial to assess the patient's bleeding risk and thrombotic risk.
- High bleeding risk is defined as a 30-day risk of major bleeding ≥2% 1.
- Low/moderate bleeding risk is defined as a 30-day risk of major bleeding <2% 1.
- Minimal bleeding risk is defined as a 30-day risk of major bleeding 0% 1. The guideline provides a detailed table (Table 13) outlining the recommended management of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) based on the patient's bleeding risk and renal function 1. For example, for patients taking apixaban, edoxaban, or rivaroxaban with high bleeding risk, these medications should be withheld for at least 24-48 hours before surgery 1. In patients with renal impairment (CrCl <30 mL/min), the duration of withholding may need to be extended 1. The decision to withhold anticoagulants should be made on a case-by-case basis, taking into account the individual patient's risk factors and the specific procedure being performed 1. It's also important to consider the use of bridging anticoagulation with parenteral heparin in select patients with high thrombotic risk 1. Ultimately, the goal is to balance the risk of bleeding against the risk of thromboembolism, and to make informed decisions based on the latest evidence and guidelines 1.
From the Research
Recommended Duration for Withholding Anticoagulants Post-Orthopedic Surgery
The recommended duration for withholding anticoagulants (blood thinners) post-orthopedic surgery varies depending on the type of surgery and the patient's individual risk factors.
- For patients undergoing high bleeding risk procedures, such as major orthopedic surgery, it is recommended to stop anticoagulants 2 days prior to the operation and restart 2 days after 2.
- For patients undergoing low to moderate bleeding risk procedures, anticoagulants should be discontinued 1 day before the operation and restarted 1 day after 2.
- Extended-duration prophylaxis (for 4 to 5 weeks) is recommended for patients undergoing hip arthroplasty or hip fracture repair 3.
Factors Influencing Anticoagulant Management
Several factors influence the management of anticoagulants in patients undergoing orthopedic surgery, including:
- The type of surgery and associated bleeding risk
- The patient's individual risk factors for thrombosis and bleeding
- The type of anticoagulant being used (e.g. warfarin, direct oral anticoagulants)
- The need for bridging with different anticoagulants 4
Guidelines for Anticoagulant Management
Guidelines from various organizations, such as the American College of Chest Physicians (ACCP), provide evidence-based recommendations for the management of anticoagulants in patients undergoing orthopedic surgery 3.
- These guidelines recommend the use of low-molecular-weight heparin, fondaparinux, or adjusted-dose warfarin as preferred options for venous thromboembolism (VTE) prophylaxis in patients undergoing hip or knee arthroplasty.
- The choice of anticoagulant and duration of prophylaxis should be individualized based on the patient's risk factors and the type of surgery being performed 5, 6.