Warfarin reversible A-plt non reversible Warfarin in AF ? Risk Warfarin in cardiac stent ? risk
High risk: Hx intracardiac thrombus. TIA. Stroke. Recent, recurrent UTI PE Prosthetic valve Low risk: AF DVT
Warfarine: Vit-k dependent. Clotting factor (II, VII, IX, X) T 1/2 : hr. Duration of action 2-5 days
Katholi et al TURP done for 12 pt on warfarin (INR 2.3) 33% need transfusion. Mulcahy et al Recommend start warfarin once hematuria resolved = 48hrs. High risk should received LMWH w/o risk of bleeding
Most guidelines recommend: Stop warfarin 5 days before surgery. LMWH 4days preop to 1 day preop INR must be <1.5 day of surgery
Heparin: Antithrombin, inactivate II, IX, X, XI, XII. T 1/2 1-6hr Using of Heparine pre-post TURP not increase risk of bleeding
LMWH: Inhibit factor X. T 1/2 8-10h ½ dose if cre clea < 30ml/min High risk should received LMWH preop and resume it within 48hrs. No increase risk of bleeding. Increase hospitalization and catheterization
Aspirin & NSAID: Inhibit TXA2 Stop ASA BT return tnormal in 48hrs. Sonksen 1999 Common prectice is to stop ASA 7-10D. Enver “no evidence, & harm to high risk”.
20% of pt for TURP have IHD or CVA. Gyomber Nielsen et al 2000: Randomize trial. TURP (continue vs holding ASA for 10d) No significant intra-op bleeding loss. Postoperative higher blood loss (284ml vs 44ml) No difference in transfusion or cauterization.
Ehrlich et al 2007: No increase of bleeding if ASA resume at stopping irrigation vs 21 days.
The American College of Chest Physicians: Suggest to continued ASA perioperatively in high- risk pt undergo noncardiac surgery, but stop ASA in low risk and resume it within 24hrs post-op.
NSAID can be withheld a week before surgery.
Thienopyridines: ADP receptor blocker. Platelet function return after 7 days.
Incidence of stent thrombosis: 31% of clopidogrel stopped 0% if dual anti-plt Schouten 2007
The American College of Chest Physicians: Clopidogrel should toped 7 days pre-op. Prostatic surgery should be postpone 12w after coronary stent.
Finastride stop 98% of idiopathic prostate bleeding. Donohue 2004 Bleeding is 7.6ml/gm (Fins) 14mlml/gm (control). Ozdal 2005 Dutasteride study no difference. Increase the cost
Antifibrinolytics “Tranexamic acid” Dose 1gm Q6hr (IV, intravesical). It decrease the amount of bleeding & irrigated fluid used. Can be used in high risk pt for bleeding.