Register Login

Bridging with Antithrombotics During Orthopedic Surgery

Here is a surgery question from Dan Southern, friend and retired professor from Western Carolina University’s Clinical Laboratory Science program:

After meeting with my surgeon, I started in motion something that I want your opinion on.He told me that I would be on Coumadin prior and six weeks after hip replacement surgery Based on experience, I don’t like Coumadin so I asked if I could wean off my current Plavix and aspirin to Lovenox pre-op and then switch back to Plavix and aspirin post-op. To my surprise, I got my wish. I will inject my abdomen six days pre-op and a few days (to be determined) after discharge with the pre-filled syringes.

Did my surgeon and I make the right decision? Should I have just gone along with Coumadin? What you would do if it were you? The surgeon actually prefers Lovenox but seldom has anyone willing to do the self injections. I can still reverse the decision. Dan

Hi, Dan. The current standard of practice is provided in Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy. American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest 2008; 133: 299-339S. To see the article you may want to go online to, although ACCP charges $12.00 for the article. You can also purchase the whole June Chest supplement for $35.00. The article definitely favors low molecular weight heparin (Lovenox or Innohep) over Coumadin for “bridging” during major surgery, and it also offers the option of discontinuing Plavix for 7 to 10 days but continuing with aspirin (Recommendation 4.5, page 321S). The article does not support Coumadin for perioperative coverage.

This is a judgment call for you and your surgeon, balancing the need to prevent a new vascular event with the high risk of intraoperative bleeding during orthopedic surgery. The value of low molecular weight heparin over aspirin is its short half-life, reducing the risk of long-term bleeding. Also, despite textbook statements to the contrary, low molecular weight heparin can be reversed using protamine sulfate. On the other hand, the risk in this approach is that the Lovenox may not be as protective as aspirin. Geo

Comments (0)

No comments here.

Leave a Reply