From the Guidelines
Lovenox should be held approximately 24 hours before surgery in patients receiving therapeutic-dose bridging anticoagulation. This recommendation is based on the American College of Chest Physicians evidence-based clinical practice guidelines, which suggest administering the last preoperative dose of low molecular weight heparin (LMWH) approximately 24 hours before surgery instead of 12 hours before surgery 1.
When considering the management of antithrombotic therapy in the perioperative period, it's essential to balance the risk of bleeding against the risk of thrombosis. The guidelines provide recommendations for the interruption of therapeutic-dose bridging LMWH, suggesting that withholding the last dose before surgery can minimize the residual anticoagulant effect at the time of surgery 1.
Key considerations include:
- The type of surgery and its associated bleeding risk
- The patient's renal function, as severe kidney impairment may require extended discontinuation periods
- The dose and frequency of Lovenox administration, with therapeutic doses requiring longer discontinuation periods than prophylactic doses
- The timing of Lovenox resumption postoperatively, which should be determined by the surgical team based on the specific procedure and patient factors.
In general, for most surgeries, Lovenox can be discontinued 12 hours before the procedure if using prophylactic doses and 24 hours before surgery if using therapeutic doses. However, high bleeding risk procedures or patients with severe kidney impairment may require longer discontinuation periods. The most recent and highest quality evidence supports holding Lovenox approximately 24 hours before surgery in patients receiving therapeutic-dose bridging anticoagulation 1.
From the Research
Perioperative Management of Lovenox
The management of Lovenox (enoxaparin) in the perioperative period is crucial to prevent thromboembolic complications and minimize the risk of bleeding.
- The timing of holding Lovenox before surgery depends on the patient's individual risk factors and the type of surgery being performed 2.
- For patients on Lovenox, it is generally recommended to stop the treatment at least 12 hours before surgery and resume it once hemostasis is achieved, usually within 24 hours 2.
- In some cases, Lovenox may be stopped 24 hours before surgery, and anticoagulation can be restarted if proper hemostasis has been confirmed 3.
- The use of bridging therapy with Lovenox has been shown to be effective in preventing thromboembolic complications in patients undergoing surgery, with a low incidence of major bleeding 3, 4.
Risk Assessment and Management
- Patients undergoing surgery should undergo a thorough risk assessment for thrombosis and bleeding, using validated risk-assessment models such as the Caprini score 5.
- The risk of thrombosis can be estimated based on patient- and procedure-specific factors, and patients can be stratified into low-, moderate-, or high-risk categories 5.
- Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced, and pharmacological prophylaxis can be reconsidered 5.
- The management of Lovenox in the perioperative period should be individualized based on the patient's risk factors and the type of surgery being performed 3, 4.
Specific Recommendations
- For patients undergoing minor surgery, Lovenox can be stopped 12 hours before surgery and resumed once hemostasis is achieved 2.
- For patients undergoing major surgery, Lovenox may be stopped 24 hours before surgery, and anticoagulation can be restarted if proper hemostasis has been confirmed 3.
- The use of bridging therapy with Lovenox should be considered on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgery being performed 3, 4.