The proper handling of antiplatelet agents in the perioperative period is important.
(1) Stop the agents entirely and significant thrombotic events can occur.
(2) Continue the agents and perioperative bleeding may be a problem.
Recommendations:
(1) If bleeding is expected, discontinue drugs with a prolonged antiplatelet effect (aspirin, clopidogrel, ticlopidine) 7 to 10 days prior to surgery and substitute a short-acting NSAID (flurbiprofen) instead.
(2) Discontinue the short-acting NSAID 24 hours prior to the start of surgery.
(3) Restart the antiplatelet agent within the first 6 hours after the surgery is complete.
Platelet transfusions should only be given if the patient develops overt bleeding. They should not be given prophylactically.
where:
• If the patient requires emergency surgery and a long-acting antiplatelet agent cannot be stopped in advance, then many surgeons will administer platelets preoperatively if they think that there is a risk for excessive bleeding. The SFAR recommendations do not support this practice without evidence of actual bleeding.
• Severe thrombocytopenia would be a reason to give a preoperative platelet transfusion.
Types of invasive procedures where preoperative antiplatelet therapy may cause significant bleeding:
(1) hip surgery
(2) tonsillectomy
(3) cardiac surgery
(4) prostate surgery via the abdominal approach
(5) intracranial surgery
(6) general surgery
Types of invasive procedures where antiplatelet therapy is not associated with significant bleeding:
(1) carotid artery surgery
(2) delivery
(3) peripheral nerve block
Specific prohibitions:
(1) spinal or epidural anesthesia: clopidogrel or ticlopidine
(2) ophthalmological procedures: thienopyridine
Additional factors that may contribute to a bleeding tendency:
(1) hypertension
(2) anticoagulation therapy
(3) hereditary or acquired coagulopathy, including thrombocytopenia
(4) hypothermia
