Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Miscellaneous issuesideally be continued and surgery should be deferred till thepatient has had the full one year course of clopidogrel. If thesurgery cannot wait, refer the patient to the cardiologist for anopinion.2. Patients who have not received a coronary artery stent in thepast year: clopidogrel should be stopped between five andseven days preoperatively. This helps to replenish half theplatelet pool reducing the chances of bleeding. After five days ofabstinence from clopidogrel, patients can receive generalanaesthesia or a regional technique.3. If in doubt consult the cardiologists or the physicians responsiblebefore stopping clopidogrel.Emergency Cases:1. Patients for emergency surgery who are on clopidogrel are atincreased risk of bleeding as the platelet dysfunction isirreversible. Bleeding could be 30% to 100% more than normal.2. These patients are best dealt with by senior surgeons andanaesthetists. Blood transfusions and cell salvage may beindicated.3. Platelet transfusion may help to control bleeding but maypredispose to thrombus formation in narrowed arteries. Defertransfusion as long as possible and use cautiously only ifbleeding is otherwise not controlled.4. In difficult cases the drug may have to be discontinued inconsultation with the cardiologists. Stopping clopidogrel even fora day can reduce blood loss as long it is not given on the day ofsurgery.5. Aprotinin: randomised controlled trials have shown thatadministration of aprotinin limits blood loss. The benefits ofAprotinin should be weighed against the risk of seriousanaphylaxis and renal damage. Aprotinin has now beentemporarily withdrawn by Bayer pending further trials.Anaesthetists Handbook January 2010 199