What guidelines should I follow for managing anticoagulation in patients undergoing surgery?

Management of anticoagulation in patients undergoing surgical procedures involves careful risk assessment and balancing the risk of venous thromboembolism (VTE) against bleeding risk.

All surgical patients should have their VTE and bleeding risk assessed as soon as possible after admission or by the first consultant review, using a validated risk assessment tool such as the Department of Health VTE risk assessment tool.

Pharmacological VTE prophylaxis with low molecular weight heparin (LMWH) is recommended for a minimum of 7 days in patients undergoing surgeries such as oral/maxillofacial, ENT, cardiac, and open vascular surgeries if their VTE risk outweighs their bleeding risk.

For patients at increased risk of VTE but with high bleeding risk or contraindications to pharmacological prophylaxis, mechanical prophylaxis using anti-embolism stockings or intermittent pneumatic compression devices should be used until the patient no longer has significantly reduced mobility.

Patients on anticoagulation for atrial fibrillation should not stop anticoagulation solely because atrial fibrillation is no longer detectable; decisions to stop should be based on reassessment of stroke and bleeding risk using CHA2DS2-VASc and ORBIT scores and patient preferences.

In the perioperative period, consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery to reduce VTE risk, with advice on alternative contraception.

Early mobilisation and adequate hydration postoperatively are important adjuncts to reduce VTE risk.