From the Guidelines
Subcutaneous heparin should be stopped 24 hours before surgery for therapeutic doses and 12 hours before surgery for prophylactic doses, as recommended by the American College of Chest Physicians evidence-based clinical practice guidelines 1. When considering the management of antithrombotic therapy in the perioperative period, it is crucial to balance the risk of thrombosis against the risk of bleeding. The guidelines suggest that for patients receiving bridging anticoagulation with therapeutic-dose subcutaneous low-molecular-weight heparin (LMWH), administering the last preoperative dose 24 hours before surgery is a reasonable approach to minimize bleeding risk while maintaining thromboprotection 1. Key considerations include:
- The type of surgery and its associated bleeding risk
- The patient's individual thrombotic risk factors, such as mechanical heart valves or recent venous thromboembolism
- The specific type and dose of heparin being used
- The need for a bridging strategy in high-risk patients After surgery, heparin can usually be resumed 24 hours postoperatively when adequate hemostasis is achieved, but this should be determined on a case-by-case basis in consultation with the surgical and anesthesia teams 1. In general, the decision to stop heparin should be individualized based on the patient's unique risk profile, and communication with the surgical team is essential to ensure optimal management.
From the Research
Stopping Subcutaneous Heparin Before Surgery
- The decision to stop subcutaneous heparin before surgery depends on various factors, including the type of surgery, patient's risk of bleeding, and risk of venous thromboembolism (VTE) 2, 3.
- There is no clear consensus on when to stop subcutaneous heparin before surgery, but it is generally recommended to discontinue it 6 to 12 hours before the procedure to minimize the risk of bleeding 4.
- However, the optimal timing for stopping subcutaneous heparin may vary depending on the specific clinical situation and the patient's individual risk factors 5, 6.
- It is essential to weigh the risks and benefits of continuing or discontinuing subcutaneous heparin before surgery, taking into account the patient's overall health status, the type of surgery, and the potential consequences of bleeding or VTE 2, 3.
Considerations for Stopping Subcutaneous Heparin
- Patient's risk of bleeding: Patients with a high risk of bleeding may require earlier discontinuation of subcutaneous heparin to minimize the risk of perioperative bleeding 6.
- Type of surgery: The type of surgery and the associated risk of bleeding may influence the decision to stop subcutaneous heparin before surgery 5, 4.
- Patient's risk of VTE: Patients with a high risk of VTE may require continued thromboprophylaxis with subcutaneous heparin or alternative anticoagulants 2, 3.
- Alternative anticoagulants: The use of alternative anticoagulants, such as fondaparinux or low-molecular-weight heparin, may be considered in patients who require continued thromboprophylaxis before surgery 6.