Anti-coagulation
Why might anti-coagulation be stopped pre-operatively?
- To facilitate safer surgery
- To allow regional anaesthesia techniques to be performed safely
- Spinal and epidural anaesthesia require INR < 1.5
| Anti-coagulant |
Administration |
When to stop |
Notes |
| Heparin, LMWH |
SC |
Discuss with anaesthetist and surgeon |
Implications for both surgery and planning central neuraxial anaesthesia |
| Rivaroxaban |
Oral |
Stop 48 hours before surgery |
|
| Dabi |
Oral |
Stop before surgery |
For neurosurgery and lower limb/pelvic surgery stop 4 days before surgery |
For all other surgery stop 48 hours before surgery |
| Apixaban | Oral | Stop 48 hours before surgery | |
| Edoxaban | Oral | Stop 48 hours before surgery
If eGFR 15-50 ml/min, stop 72 hours before surgery
| |
| Warfarin | Oral | See notes | Low risk of bleeding in peri-op period - stop 5 days before surgery
High risk of complications if warfarin is stopped - discuss with anaesthetist |
Antacids
- Antacids are important in reduction of gastric acid reflux or aspiration risk at induction of anaesthesia
- Patients should have taken their usual dose and any prescription from PAC has been given
- Can be given on morning of surgery
- Patients with a BMI > 30 are offered ranitidine via a pathway at PAC
Anxiolytics
Benzodiazepines
- Midazolam: has a quick onset and short duration of action, it is commonly given as sedation for regional anaesthesia or procedures such as endoscopy
- It can also be used to relieve anxiety prior to the induction of anaesthesia
- Temazepam: has a slower onset of action than midazolam and can be given as a ‘pre-medication’ the night before or morning of surgery
- Lorazepam and diazepam: are used in the immediate management of seizure
- Diazepam is also prescribed for anxiety disorders and muscle spasms
Mechanism of action
- Benzodiazepines bind to the GABA receptor in the CNS
- They increase the receptor affinity for GABA. Ion movement across the cell membrane is increased
- This hyperpolarises the cell membrane and reduces firing of neurons
- With the CNS depressed, the patient might appear more relaxed, drowsy, disinhibited and have amnesia
Intravenous anaesthetic induction agents