In Poland, surgeons and internists often have different approaches to perioperative anticoagulation. What would be your advice for a physician who prepares and qualifies a patient for surgery and struggles to find a middle ground between the expectations of a surgeon and an internist?
James Douketis: This happens a lot in everyday practice. There is the tension between the surgeon, the internist or family physician, and sometimes even the anesthesiologist. How do we reconcile these views? From my perspective, the common element to all those areas is to mitigate or prevent major or serious perioperative bleeding. So whatever we do, if we use bridging therapy or no bridging therapy, we want to try to minimize the risk for bleeding in the operating room and afterwards.
The second point is that all of these physicians need to have a basic understanding of what are the properties of the blood thinners – whether it is warfarin, acenocoumarol, novel oral anticoagulants (NOACs), or aspirin – so they understand their pharmacokinetic properties. That is important in the perioperative or periprocedural setting, because you can get an idea how long these drugs need to be off so that there is no remaining antithrombotic effect. So having that kind of knowledge.
The final piece is communication, because every patient is different. Let’s take a very complex example: a patient who just had a coronary stent put in for heart attack but now needs to have cancer surgery that we do not want to delay. How do we manage that patient? That needs a discussion between the internist, the surgeon, and the anesthesiologist to come up with a plan.