Policy for effecting skin surgery when patients are on thrombosis preventing medications
ASPIRIN
1) Aspirin should not be ceased for skin surgery
2) It could be considered negligent if a patient suffered a major thromboembolic event subsequent to aspirin being ceased for skin surgery
WARFARIN
1) Warfarin should usually be continued before and after skin surgery
2) INR should be checked prior to surgery to ensure it is within therapeutic range and below 3.0
3) Warfarin should not be ceased if the patient has suffered a major thromboembolic event within a month
4) Warfarin can be considered for temporary cessation when quite large procedures with complex reconstructions are being envisaged on older patients, especially if the surgery is a major ear reconstruction. In general circumstances, consideration of cessation of warfarin should comprise no more than 2% of occasions in which a patient on warfarin faces skin cancer surgery.
TICLOPIDINE and CLOPIDOGREL
1) Less evidence exists regarding the risk of bleeding faced by patients taking these agents compared with our knowledge of warfarin and aspirin.
2) In general these agents should be considered for continuation for skin surgery unless circumstances of significant bleeding risk are anticipated by the surgeon
HAEMOSTASIS
1) Skin surgery should be undertaken with the skills and equipment available to manage intra-operative bleeding should this become an issue
2) Diathermy availability is recommended, preferably bipolar diathermy if skin flap surgery is planned
3) Sutures suitable for vessel ligation and the surgical skills to do so are also recommended.
4) Minimising bleeding complications requires competence at managing intraoperative bleeding.
Further reading:
About the risks of short term ceasing warfarin and aspirin prior to surgery we recommend:
Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997;336:1506-11.
About the bleeding risks when patients stay on warfarin and aspirin for skin surgery we recommend:
Dixon AJ, Dixon MP, Dixon JB. Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy. Br J Surg 2007;94:1356-60.
Full text available here: http://skincanceronly.com.au/Research/Warfarin_aspirin.aspx