Perioperative evaluation and management in dermatologic surgery

A review of traditional and novel oral anticoagulant and antiplatelet therapy for dermatologists and dermatologic surgeons

“…72 It is agreed that this relatively high risk of thrombotic complications outweighs the much lower risk of serious hemorrhagic complications with continued anticoagulant therapy. In 2002 it was reported that up to 80% of Mohs surgeons discontinued warfarin therapy perioperatively, compared with 44% in 2005 19,73 ; we anticipate that this percentage currently is far less. This finding represents a dramatic paradigm shift by dermatologic surgeons in the perioperative management of all anticoagulant therapies.…”

“…16,18 Although some studies have shown a lack of bleeding complications during cutaneous surgeries in patients taking warfarin, a meta-analysis encompassing a total of 1373 dermatologic surgery patients found that those taking warfarin were nearly 7 times as likely to have moderate to severe bleeding-related complications (Table III) compared with control subjects. 4,5,19 Furthermore, recent prospective studies have demonstrated a statistically significant increase in hemorrhagic complications in patients taking warfarin. 1 Certain patient characteristics have been identified in the Outpatient Bleeding Risk Index as validated risk factors for major spontaneous or perioperative bleeding events.…”

“…Although a meta-analysis of dermatologic surgery patients taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) showed patients had greater than a 2-fold increased risk of developing a moderate to severe bleeding complication (Table III) as compared with control subjects, it did not meet statistical significance; further studies have failed to show any increased bleeding risk in dermatologic surgery patients when taking aspirin or other NSAIDs. 1,4,5,19 Clopidogrel…”

“…Aspirin/NSAIDs 19 1. Patient may discontinue aspirin 10 d or NSAIDs 3 d before operation if the reason for taking the medication is related to either primary prevention of stroke or heart attack (no history of either) or for headaches or pain only.…”

“…Warfarin 19 1. Obtain patient's most recent INR within 1 mo before surgery to be sure the warfarin level is within the therapeutic range (2-3.5).…”