Outpatient management of the chronically anticoagulated patient for elective surgery.

With the appropriate use of preadmission clinics, "hospital in the home" programs, and alternatives to intravenous heparin, the majority of chronically anticoagulated patients can be managed as outpatients prior to elective surgery. The preoperative management depends on the original indication for long-term anticoagulation, the interval since the last thromboembolic event, and the extent and type of surgery planned. Only patients who are undergoing major surgery, and who have a high risk of recurrent thrombosis or embolism, require preoperative admission to hospital and conversion to an intravenous heparin regimen. Patients undergoing minor surgery may require no change to their oral anticoagulation. The remainder require cessation of oral anticoagulation and alternative thromboprophylaxis preoperatively, which can be achieved on an outpatient basis using low molecular weight heparin. Outpatient anticoagulation management requires a clear protocol that is understood and agreed to by all parties involved in the care of surgical patients perioperatively.