From the Guidelines
Heparin infusions should be stopped at least 4 hours before surgery to minimize the risk of perioperative bleeding, as recommended by the American College of Chest Physicians clinical practice guideline [ 1 ].
Key Considerations
- The exact timing of heparin discontinuation may depend on the specific surgical procedure and the patient's risk factors, with major surgeries potentially requiring a longer discontinuation period.
- A PTT or anti-Xa level should be checked before surgery to confirm that anticoagulation has adequately reversed.
- The short half-life of unfractionated heparin (approximately 60-90 minutes) allows for a relatively brief discontinuation period.
- For patients at high thrombotic risk, bridging with shorter-acting anticoagulants might be considered in consultation with the surgical team.
Post-Surgery Management
- After surgery, heparin can typically be resumed 12-24 hours post-procedure, depending on hemostasis and bleeding risk.
- This timing balances the need to prevent perioperative bleeding while minimizing the risk of thrombotic events during the period without anticoagulation, as suggested by the American College of Chest Physicians [ 1 ].
Evidence-Based Recommendation
The most recent and highest quality study, published in 2022 in the journal Chest [ 1 ], provides a conditional recommendation to stop UFH at least 4 hours before a surgery/procedure, which is the basis for the recommendation to discontinue heparin infusions at least 4 hours before surgery.
From the Research
Discontinuation of Heparin Infusion Prior to Surgery
- The decision to discontinue heparin infusion prior to surgery depends on various factors, including the type of surgery, patient's risk of thromboembolism, and the specific heparin product being used 2.
- For patients on unfractionated heparin therapy, it is recommended to stop the infusion 4 to 6 hours before surgery and resume once hemostasis is achieved, usually within 24 hours 2.
- Low-molecular-weight heparin, on the other hand, is typically stopped at least 12 hours before surgery and then resumed in a similar fashion 2.
- Other studies have also investigated the use of heparin bridging therapy in patients undergoing surgery, with some suggesting that low-molecular-weight heparin may be a safe alternative to unfractionated heparin 3, 4.
- However, the optimal timing for discontinuing heparin infusion prior to surgery may vary depending on the specific clinical context and patient population, and should be individualized based on the patient's risk factors and medical history 5, 6.
Considerations for Specific Surgical Procedures
- For patients undergoing abdominal surgery, one study found that low-molecular-weight heparin was effective in preventing postoperative venous thromboembolism, with no significant difference in bleeding complications compared to unfractionated heparin 5.
- In patients undergoing coronary artery bypass grafting surgery, another study found that pre-operative administration of enoxaparin or unfractionated heparin did not significantly affect peri-operative bleeding or coagulation parameters 4.
- For endoscopic procedures, the risk of bleeding may be lower, and heparin infusion may not need to be discontinued, although this depends on the specific procedure and patient's risk factors 6.