Abstract
Purpose: This study was performed to assess the utility and safety of an In-Office INR Monitoring Device and present a safe and efficient protocol for the management of patients on oral anticoagulants and/or antithrombolytics requiring routine office oral and maxillofacial surgery. Patients and Methods: Sixty-one patients requiring “minor” oral and maxillofacial surgery being treated chronically with oral anticoagulation (warfarin) were entered into the study and compared in 2 groups. The control group (n = 29) was managed by discontinuing warfarin and any anti-platelet medication(s) prior to surgery. In the study group (n = 30), the decision to continue or withhold warfarin was determined by a protocol in which patients are 1) stratified based on risk for thromboembolism, and 2) classified as requiring “major” or “minor” surgery. Procedures categorized as “minor” surgery included dental extraction(s), dental implants, soft tissue and bone biopsies, and preprosthetic bone surgery, and incision and drainage. Warfarin and antiplatelet medication were not withheld in these patients, and a Point-of-Care In-Office INR Monitoring Device was used to obtain INR levels on the day of consultation and surgery. Local measures including removal of granulation tissue, packing, suturing, etc. were utilized for hemostasis. Results: The 30 patients in the study group maintained on warfarin readily achieved hemostasis using intraoperative local measures. The mean INR measured by the In-Office INR Monitoring Device was 2.36 with a range from 1.3 to 3.2. Study group patients underwent a total of 131 separate procedures including 108 dental extractions (impactions), placement of dental implants, preprosthetic bony surgery, bone cyst removal, soft tissue biopsies, facial skin cancer repair, and incision and drainage. One patient (3%) required “minor” intervention with removal of a “liver clot” on postop day 2 with repacking and suturing. The 29 patients in the control group discontinued off of war farin underwent a total of 99 procedures. One patient (3%) also required a “minor” intervention (repacking of extraction site). There were no “major” complications in either group. Conclusions: This study supports previous studies that minor oral surgery procedures can be safely performed while maintaining patients on warfarin minimizing the risk of a potentially devastating thromboembolic event. When deciding whether or not to withhold warfarin, this study supports the use of the proposed protocol based on 1) risk stratification for thromboembolism, 2) the need for “minor” versus “major” surgery, 3) and utilization of an In-Office INR Monitoring Device. An In-Office Point-of-Care INR measuring device can be a very effective tool to safely simplify and make the perioperative management of the anticoagulated patient more efficient for the patient and oral and maxillo facial surgeon.
Highlights
The perioperative management of the anticoagulated patient can be an inconvenient and cumbersome process for both the patient and surgeon, commonly involving direct communication with the treating physician, the discontinuation of warfarin, synchronized office visits, OPEN ACCESSG
Warfarin and antiplatelet medication were not withheld in these patients, and a Point-of-Care In-Office International Normalized Ratio (INR) Monitoring Device was used to obtain INR levels on the day of consultation and surgery
When deciding whether or not to withhold warfarin, this study supports the use of the proposed protocol based on 1) risk stratification for thromboembolism, 2) the need for “minor” versus “major” surgery, 3) and utilization of an In-Office INR Monitoring Device
Summary
The perioperative management of the anticoagulated patient can be an inconvenient and cumbersome process for both the patient and surgeon, commonly involving direct communication with the treating physician, the discontinuation of warfarin, synchronized office visits, OPEN ACCESSG. The perioperative management of the anticoagulated patient can be an inconvenient and cumbersome process for both the patient and surgeon, commonly involving direct communication with the treating physician, the discontinuation of warfarin, synchronized office visits, OPEN ACCESS. Oral and maxillofacialsurgeons may benefit from incorporating Point-of-Care coagulometers into the office to simplify the process of managing anticoagulated patients for both the patient and doctor. The controversy [1,2] over the approach options when managing perioperative patients treated with oral anticoagulation may include one of the following three protocols: 1) continuing warfarin (Coumadin , Dupont Pharmaceuticals, Wilmington, Del.) therapy; 2) withholding warfarin therapy for a specified period of time before and/or after the procedure; 3) temporarily withholding warfarin therapy while a using a “heparin bridge”
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