27 Preoperative Preparation and Instruction
Summary
Keywords: complication hypertension atrial fibrillation NOAC DOAC DAPT antithrombotic therapy informed consent coronary artery stent
Key Points
•Physicians should use a surgical checklist and preoperative handouts to ensure the “routine” preoperative steps and instructions are covered thoroughly.
•“Specific” preoperative modifications based on a patient’s preexisting medications or conditions (discovered by the directed medical history) should be addressed before surgery.
•Antihypertensive drugs including a beta-1 selective blocker should usually be maintained in the therapeutic dose before hair transplantation.
•Different forms of antithrombotic therapy may be present due to the presence of various preexisting conditions.
•Usually aspirin should be continued before surgery in patients with a coronary artery stent.
•Low-intensity warfarin should be continued before surgery in patients with a mechanical heart valve.
•Direct oral anticoagulant (DOAC) should be continued in the maintenance dose or in a reduced dose before surgery in patients with atrial fibrillation.
27.1 Introduction
The preoperative phase is an important part of the hair transplant process. Once the surgical plan has been made and the patient has scheduled, there are a number of preoperative events that should occur to ensure a safe and successful hair transplant procedure. Some preparations are routine steps that apply to all patients. These will be discussed first. However, on occasion, findings in the directed medical history necessitate additional steps to ensure the safety of the patient (see Chapter 16. In this chapter, we focus more on pre- and perioperative measures that should be taken to prevent problems from occurring(see Chapter 33: Emergency Preparedness in Hair Restoration Surgery).
27.2 Coordination of Preoperative Events and Dissemination of Information
27.2.1 Preoperative Checklist
There are a number of preoperative events that should occur to help ensure a smooth and successful hair transplant procedure. It is helpful to delegate a specific staff member to be a patient coordinator to ensure no steps are overlooked. A preoperative checklist attached to the chart and reviewed by the patient coordinator is a useful tool (Appendix 27.A).
27.2.2 Preoperative Package
Once the patient has been scheduled for surgery, many practices send out a preoperative package that includes the following:
•A Confirmation Letter reviewing the plan, date, time, and financial arrangement.
•Routine Preoperative Instructions tailored to the procedure (follicular unit excision [FUE] or follicular unit transplantation [FUT]; Appendix 27.B).
•A map to the office with a list of suggested hotels if the patient is from out of town.
Some practices find it useful to include additional information, at this time including the Postoperative Informed Consent Form (Appendix 27.C), Postoperative Instructions Sheet (Appendix 49.A), and What to Expect after Surgery Handout (Appendix 49.B). This allows the patient time to become familiar with this is information before surgery, making it easier for them to understand when presented again on the day of surgery.
The informed consent should include the usual outcomes of the procedure, details of alternative treatments, and possible complications and risks. All aspects of the informed consent should be explained in easy-to-understand, nontechnical terms. Informed consent does not exempt the surgeon from responsibility or from performing up to the standards.1
Pre-op packages are typically sent to patients 10 weeks before the date of surgery. Again, it is helpful to delegate a patient coordinator to make sure the patient receives all preoperative materials, and to be available for questions and help with arrangements.
27.3 Routine Preoperative Instructions
27.3.1 Clothes to Wear
27.3.2 Hair Washing and Dying
Patients should wash their hair the night and possibly morning before surgery. Some physicians recommend a Hibiclens shampoo. Active folliculitis or seborrheic dermatitis should be treated and cleared before surgery.
Dying gray or white 3 to 4 days before surgery helps improve visibility during donor harvesting and making recipient sites.
27.3.3 Hair Length
•Strip-FUT: We tell patients not to cut their hair in both the donor and the recipient area before surgery for strip-FUT. Longer hair in the donor area is used to cover the strip incision. Longer hair in the recipient area gives us the option of styling to cover recipient incisions post-op.
•Scalp FUE: We tell the patients not to cut their hair before surgery in the recipient area with FUE. Cutting the recipient area short may make the pattern of hair loss harder to see. We want the opportunity to see the hair loss pattern before cutting the recipient area short. In addition, sometimes we can use the longer recipient area hair to create a “high and tight” hairstyle. Since there is no strip scar to cover, we do allow them to cut the scalp donor areas short as a no. 1 guard before surgery.
•Body hair/beard hair FUE: The situations for body and beard hair are different in that the patient should “wet” shave the donor area (chest or beard) about 5 to 7 days before surgery. Only the hairs in the anagen phase will regrow over the next 5 days, helping physician identify the best hairs to harvest for transplantation.
27.3.4 Scalp Exercises for Strip Follicular Unit Transplantation
Scalp exercise should be started 1 to 2 months before surgery for tight scalps in strip-FUT. This can significantly increase laxity, which in turn increases the width of the strip that can be harvested as well as lowers the risk of scarring (Video 27.1).
27.3.5 Activity and Exercise
Some clinics recommend that the patient refrain from strenuous exercise or activity a few days before surgery as it theoretically leads to a decrease in platelets.
27.3.6 Transportation
Most clinics tell patients to arrange for a driver to pick them up after surgery due to the administration of sedatives, anxiolytics, or pain medication during the surgery.
27.3.7 Eating
Most of the time, the procedure is done under local anesthesia, so patients do not have to refrain from eating. In fact, they should be told to eat a good breakfast and drink plenty of fluids in order to prevent them from getting dehydrated and weak during this fairly long (4–8+ hours) procedure.
27.3.8 Over-the-Counter Medications and Substances to Avoid
Do to the high vascularity of scalp and the difficulty that increased bleeding causes with making incision and placing grafts, we are extra cautious about limiting over-the-counter (OTC) medications and substances that could potentially increase bleeding.
•Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDS): Both these OTC medications inhibit platelet function and we typically recommended that they be stopped before surgery. Acetylsalicylic acid (ASA) irreversibly inhibits cyclooxygenase, which inhibits thromboxane synthesis, leading to decreased platelet function.2 ASA’s effect lasts for the lifetime of the platelet or approximately 7 to 10 days; therefore, ASA should be stopped 10 days before surgery. Many cold and flu products contain ASA and patients should check the labels of any OTC medications they are taking. NSAIDs (Motrin, Aleve, etc.) also inhibit cyclooxygenase, but their action is reversible and usually they can be stopped sooner.
•Although this is the official recommendation, some studies and empirical observation have shown that often bleeding does not seem to be increased to a clinically significant extent when patients forget to stop these mediations. If aspirin is being taken for cardiac disease, it should not be stopped without permission from the patient’s primary care physicians.
•Alcohol: Both acute and chronic alcohol consumption can increase bleeding. It is common to encourage patients to avoid alcohol for 7 days before surgery. Once again, it is rare to see increased bleeding if a patient has simply had one or two drinks the week before surgery.
•Vitamins and herbs: There are a number of vitamins, herbs, and foods that are said to affect platelets and potentially increase bleeding. These include vitamin E, fish oil, curry, and many others. We used to give a list of all these foods to patients, but following this diet is not practical and there are few studies that show they actually increase bleeding to clinically significant extent. Therefore, from a practical standpoint, telling the patient to simply stop his OTC vitamins and herbal supplants for a week or so before surgery is probably more than adequate.3
•Minoxidil: When minoxidil was first introduced, there was concern that it could cause increased bleeding because it is a vasodilator. Today most physicians feel it does not cause bleeding and is safe to use up to surgery. Some feel minoxidil may be irritating to the immediate post-op recipient site incisions and it may be prudent to wait 3 to 4 days after surgery before restarting minoxidil.
•Tobacco and nicotine: Obviously smoking before, during, and after surgery is toxic to cells including those of follicular unit (FU) grafts. Cigarette smoke contains nicotine (an addictive vasoconstrictor), carbon monoxide (lowers oxygen delivery to cells), and many other toxic compounds.4 Many believe it is one of the more important preoperative factors responsible for poor growth. Vaping and chewing tobacco are probably not as bad as smoking, but still contain nicotine. Patients are encouraged to decrease or stop smoking as much as possible before surgery. Paradoxically, during surgery, if a patient is not allowed to have a cigarette break, they can become agitated, jittery, and have increased bleeding, so it is often the lesser of two evils to let them have a break during the day.
27.3.9 Optional Vitamin K
27.4 Preoperative Preparation due to Specific Medical Conditions
Although hair transplantation is a fairly safe procedure, complications and even fatalities (which have been reported) can occur. The risk increases with certain underlying medical conditions and it is important to do a directed medical history at the time of the consult to identify patients at greater risk. Coronary diseases, valvular heart disease, asthma, diabetes, deep vein thrombosis (DVT), and antithrombotic therapy bleeding disorders (for any reason) are just some of the conditions we look for in the medical history (see Chapter 16 for more information on the directed medical history). In general, if a patient has a preexisting condition that increases surgical risk, it is best to obtaining pre-op clearance and guidance by the appropriate specialists. Some preoperative conditions that require attention are discussed in the following sections.
27.4.1 Hypertension
If a patient has a history of hypertension, they should be told to take their antihypertensive drugs as normal on the day of surgery to prevent high blood pressure (BP) during surgery. White coat hypertension is not uncommon and simply waiting, using pre-op anxiolytics and repeating the BP, is often enough to have the BP return to an acceptable range. Making sure the patient has not missed and taken his normal morning dose of antihypertensive medication is another measure that is helpful. If these measures do not work, the surgery should be postponed until the BP is brought under control. Sublingual nifedipine should not be used to acutely lower BP as it is dangerous and can cause rapid dangerous hypotension and rebound hypertension (see Chapter 33 for more discussion on emergency treatment of hypertension).
27.4.2 Antithrombotic Therapy
Antithrombotic therapy consists of antiplatelettherapy (i.e., ASA, Plavix, etc.) and/or anticoagulanttherapy (i.e., warfarin, direct oral anticoagulant [DOAC], etc.). DOACs are a new genre of non–vitamin K antagonist anticoagulants that work differently than coumadin. Examples of DOACs include dabigatran, which inhibits thrombin directly, and rivaroxaban, which inhibits coagulation factor Xa.5,6
Antiplatelet drugs prevent platelets from clumping and aggregating in fast blood flow areas such as coronary arteries, carotid arteries, and stents. Anticoagulant drugs prevent fibrin formation and inhibits clotting in slow blood flow areas such as the left atrium in atrial fibrillation (AF). Antiplatelet drugs are not effective in preventing DVT or clots forming in the atria during AF.
Patients take antithrombotic therapy for a number of medical reasons including the following: coronary artery disease (CAD) with or without stents, valvular heart disease, AF, strokes, DVT, etc. The antithrombotic treatment regime varies depending on the underlying disease and can range from simple single antiplatelet therapy and dual antiplatelet therapy (DAPT) to combined antiplatelet and anticoagulant.
When considering hair transplant surgery patients on antithrombotic therapy, the physician needs to consult and get guidance from the patient’s primary care physician to decide the following:
•If the underlying disease for which they are taking the medication is stable and allows for surgery.
•If it is safe to adjust the patient’s antithrombotic regime, and if so, how they would recommend doing this.
27.5 Ischemic Heart Disease
In patients with a history of CAD, it is important to determine the current treatment and status of the disease before accepting a patient for surgery. Patients with stable disease can be accepted for surgery after being evaluated and cleared by their primary physician. Some physicians prophylactically place nitroglycerine tape on the anterior chest wall during surgery (see Chapter 33).7
27.5.1 Coronary Artery Stent
Patients with coronary artery stents need antiplatelet drugs to prevent thrombus occlusion of the stents.7,8,9 Typically, DAPT, with a combination of Plavix (clopidogrel) and aspirin, is used for the first 2 years after a coronary stent. One should not stop DAPT therapy or adjust the antiplatelet regime if the patient’s cardiologist does not agree with this. Stent thrombosis is a serious event with high mortality.
The following are guidelines often suggested by cardiologists:
•For the first year after a coronary stent, DAPT should not be stopped, even briefly, and therefore hair transplantation cannot be done.
•One year after a coronary stent, some cardiologists will permit the brief sensation of Plavix 5 days before surgery while continuing the aspirin to make hair transplantation possible.
•Two years after a coronary stent, many patients are often switched to a single antiplatelet long-term therapy. If the single therapy used is low-dose aspirin, surgery can be usually be performed while continuing aspirin. If the single therapy is Plavix, some cardiologists will permit changing it to aspirin 1 week before the surgery and switching back after the surgery.
27.5.2 Atrial Fibrillation
AF is a common arrhythmia that carries the risk of thrombus formation in the left atrium, which can detach and can cause cerebral infarction with high mortality.10,11,12,13 Patients with AF use anticoagulant drugs to prevent clot formation in the left atrium.
Cardiologist vary in their approach to anticoagulation management during surgery in patients with AF depending on the clinical situation and their comfort level with the risk of bleeding versus thromboembolic event. Some will not allow any change to therapy, others are comfortable with a temporary dose reduction of anticoagulation, while still others will permit a temporary cessation of anticoagulant therapy. Dose reduction is probably the most common approach allowed by cardiologists. This author does in fact perform hair restoration surgery (HRS) on patients taking coumadin, if the patient’s cardiologist will not allow for discontinuation or dose reduction. A number of practitioners have reported acceptable levels of bleeding during hair transplantation on patients who have not discontinued their anticoagulation.
Stopping the anticoagulant with heparin bridging used to be popular, but it is currently not recommended by the American College of Cardiology guidelines.11
27.5.3 Mechanical Heart Valve
Patients with a mechanical heart valve need both anticoagulant and antiplatelet drugs to prevent thrombus formation on the valve.14,15,16 Valve thrombus causes acute regurgitation requiring an emergency repeat valve replacement surgery associated with high mortality. Strict control of anticoagulation is the rule and in contrast to AF, warfarin should not be discontinued before hair transplantation.
The latest guidelines for surgery in these patients recommend a dose reduction of warfarin to two-thirds or half of the therapeutic dose for several days before surgery with resumption of the maintenance dose after the surgery.5,14 The prothrombin time and international normalized ratio (PT-INR) will change from 2.0 to 3.0 (targeted maintenance PT-INR) to 1.5 to 1.8 (low-intensity warfarin) on the day of the operation, and the PT-INR will become 2.0 to 3.0 again 4 to 5 days after the surgery. Safe hair transplantation will be possible without hemorrhagic tendency under these conditions.
Bridging anticoagulation is no longer recommended by the American Heart Association/American College of Cardiology Foundation (AHA/ACCF) in these patients.5,17 Heparin does not prevent arterial thromboembolic events and heparin increases the risk of major bleeding. Vitamin K should not be used in patients with a mechanical heart valve as it will put the patient at risk of thrombosis on the valve. Antiplatelet drugs can be stopped for 2 to 7 days before surgery and should be restarted after the surgery as long as warfarin is continued as described earlier.
27.5.4 Arrhythmia
If a patient has a history of cardiac arrhythmia, it is recommended that a cardiologist determine whether the patient can safely proceed with surgery. It is the authors’ opinion that supraventricular premature contraction and isolated ventricular premature contraction are not dangerous.
Dangerous arrhythmias include Brugada’s syndrome, ventricular tachycardia (VT), and Wolff–Parkinson–White (WPW) syndrome with tachycardia, which may cause ventricular fibrillation (VF) and sudden cardiac death. The arrhythmia should be controlled by the cardiologist before hair transplantation (see Chapter 33).
27.5.5 Deep Vein Thrombosis
If a patient has a history of DVT, there is an increased risk of it recurring during the long surgery. At a minimum, the patient should be allowed to get up and walk every hour as well as wear compression stockings. Intermittent air compression devices are effective. Some physicians suggest compression stocking in all their patients even if they have no history of DVT.
27.5.6 Asthma, Chronic Obstructive Pulmonary Disease , and Sleep Apnea
Patients with bronchial asthma, chronic obstructive pulmonary disease (COPD), and sleep apnea are at risk for respiratory compromise associated with hypoxia and/or hypercapnia during a surgical procedure. Patients with asthma and COPD vary tremendously with respect to the current stability of their respiratory status. Some are totally asymptomatic and disease free in between exacerbations, while others have a constant subclinical degree of respiratory compromise that may be unrecognized. Often this is due to undertreatment or noncompliance of recent exacerbations. These patients are at particular risk of respiratory decompensation during a procedure, especially if given sedation. Only patients with stable, fully treated disease should be considered for outpatient surgery, and this determination should be made by their primary care physician. Patients with stable asthma usually do well as long as they stay on their baseline treatment and any known exacerbating factors (i.e., pulmonary irritants, allergens, etc.) are removed from the room before surgery. Patients with COPD carry a greater risk because, unlike asthma, they are usually older, have associated illnesses, and even in their best state are often somewhat respiratory compromised. All these patients should stay on their baseline medications before and during surgery. Less sedation should be used. They should have their pulse, PO2, and level of consciousness monitored. Some surgeons will not give sedation to patients with COPD without an anesthesiologist present. A dropping PO2, rising pulse, and/or decreasing level of consciousness should trigger concern and action. A first step is to stimulate the patient and tell them to take deep breaths, if insufficient administration of oxygen at 1 to 2 L/min and/or bronchodilator is appropriate. If the episode does not completely resolve, preparation for transfer to emergency services should be arranged. For more discussion of emergency intervention for COPD or asthma, see Chapter 33.
27.5.7 Von Willebrand’s Factor Deficiency
If your patient has a history of excessive bleeding, during or after prior surgeries, the possibility of a bleeding disorder such as Von Willebrand’s disease or a factor VIII deficiency should be considered. If investigation reveals a deficiency of either of the latter two factors, the use of desmopressin (DDAVP) preoperatively may prove very helpful. DDAVP is a drug that stimulates the release of factor VIII and Von Willebrand factor from the body’s storage sites. It is used for patients with mild or moderate hemophilia AA, and for some platelet disorders. Typically, DDAVP, 0.03 mg/kg, is administered 30 to 60 minutes before the patient goes to the dentist or has surgery. Maximum effects occur 1 hour after administration, with some benefit lasting for 8 to 12 hours.
27.5.8 Diabetes Mellitus
Patients with diabetes are more prone to CAD and silent ischemia, and the physician should be aware of this. Monitoring of electrocardiogram (ECG) and prophylactic use of a nitroglycerin tape may be considered in these patients. Patients on insulin should continue their normal protocol and monitor their blood sugar during the procedure. The stress of surgery and/or the use of corticosteroids typically used to prevent post-op edema could cause hyperglycemia. Meals and glucose should be available, so the patient does not go extended time after insulin without food intake Another issue is susceptibility to infection. Skin is one of the most common sites of infection in diabetic patients. Close monitoring for postoperative infection or the use of perioperative antibiotics may be recommended.
27.5.9 Allergic Reactions
Allergic reactions can result in life-threatening anaphylaxis. It is critical to ask about allergies during the evaluation and place a red tag on the chart clearly identifying the offending agent.
Antibiotics allergy:Antibiotics is one of the most common causes of allergy, with penicillin being the most common offender, followed by sulfa and cephalosporins. Risk was greater in the past when routine prophylactic antibiotics were more commonly used. Today, prophylactic antibiotics are seldom used.
Latex allergy:Allergy to latex powder on gloves is rare; however, since latex gloves are used in all surgeries, it is important to be aware of this. Latex can cause both contact dermatitis and more rarely systemic anaphylactic response that can develop immediately after latex exposure in a sensitive patient. The patient reacts to the latex powder by inhaling airborne particles that are released when latex gloves are removed. All products containing latex should be removed from the treatment areas and all staff should use latex-free nitrile gloves or nonlatex gloves.
27.5.10 Patients at Risk of Folliculitis, MRSA, or other Skin Infections
In general, due to the high blood flow from the scalp, hair transplant surgery has a low risk of skin infection and prophylactic antibiotics are seldom used. However, there are a few situations where the risk of skin infection is higher and associated with enough morbidity that consideration of peri-operative antibiotic use is indicated.
•Methicillin-resistant Staphylococcus aureus (MRSA) carrier: If identified, MRSA carriers should undergo decolonization or be treated with appropriate preoperative antibiotics such as trimethoprim/sulfamethoxazole, doxycycline, or clindamycin prior to surgery. Nasal decontamination with Bactroban (mupirocin) is also recommended.
•History of folliculitis: Folliculitis is a common post-op complication that can range from (1) a minor nuisance that resolves quickly with localized conservative treatment to (2) a chronic, relapsing, severe inflammatory process that requires fairly aggressive long-term treatment. Patients with a history of oily skin, acne as a child, or folliculitis with past procedures are at increased risk. The beard area is particularly prone to folliculitis, especially with the curly hair characteristics of black patients (see Chapter 90). In patients with increased risk, at a minimum, the physicians should maintain higher vigilance, close follow-up, and be ready to start antibiotic treatment. Early treatment can often abort an otherwise prolonged complication. It is not uncommon for physicians who have patients at higher risk (or a past history folliculitis) to use prophylactic antibiotic treatment involving various combinations of preoperative, perioperative, and postoperative prophylactic antibiotic.
27.6 Medications with Potential Adverse Interactions with Drugs Commonly Used in Hair Transplantation Surgery
Beta blockers: Beta-1 selective blockers such as atenolol and bisoprolol are usually used for refractory hypertension, dangerous tachyarrhythmia, and heart failure.11,13,18,19 The AHA/ACCF recommends continuation of beta-blockers before noncardiac vascular surgery. Beta-1 selective blockade reduces perioperative mortality.11,13,18,19 The authors do not stop beta-1 selective blockers prior to surgery, and hair transplantation can be performed as usual.
On the other hand, a non-nonselective beta-blocker may cause hypertensive crisis and anaphylaxis that does not respond to epinephrine. A nonselective beta-blocker prevents vasodilatation, leaving alpha-1 vasoconstriction, and additional systemic epinephrine may result in hypertensive emergency and reflex bradycardia. Nonselective beta-blockers should be changed to cardioselective beta-blockers prior to surgery, because cardioselective beta-blockers do not cause hypertensive reaction following systemic epinephrine. However, you should not stop or change the dosage of any medicine before checking with the patient’s cardiologist.
References
[1]Unger WP. Preoperative preparation and instructions. In: Unger WP, Shapiro R, Unger R, Unger M, eds. Hair Transplantation. 5th ed. New York, NY: Informa Healthcare; 2011:198–212
[2]Lawrence C, Sakuntabhai A, Tiling-Grosse S. Effect of aspirin and nonsteroidal antiinflammatory drug therapy on bleeding complications in dermatologic surgical patients. J Am Acad Dermatol. 1994; 31(6):988–992
[3]Nelson JL. Conventional and nonconventional medications in hair transplantation. In: Unger WP, Shapiro R, Unger R, Unger M, eds. Hair Transplantation. 5th ed. New York, NY: Informa Healthcare; 2011:221–225
[4]Black CE, Huang N, Neligan PC, et al. Effect of nicotine on vasoconstrictor and vasodilator responses in human skin vasculature. Am J Physiol Regul Integr Comp Physiol. 2001; 281(4):R1097–R1104
[5]Yagyu K. Peri-operative antithrombotic therapy in hair transplantation. Hair Transpl Forum Int. 2016; 26(6):241–251
[6]Cryder B. A Practical review of the novel oral anticoagulants. Pharmd Bcacp. Available at:https://www.ipha.org/assets/docs/Locals/tableta%20practical%20review%20of%20the%20novel%20oral%20antico
[7]Yagyu K. Safe surgery in patients with ischemic heart disease. Hair Transpl Forum Int. 2015; 25(1):28–32
[8]Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130(24):e278–e333
[9]Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guidelines focused update on duration of dual antiplatelet therapy in patients with coronary artery disease; a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2016; 134:e123–e155
[10]Wann LS, Curtis AB, Ellenbogen KA, et al. American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (update on Dabigatran): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011; 123(10):1144–1150
[11]JCS Joint Working Group. Guidelines for pharmacotherapy of atrial fibrillation (JCS 2008): digest version. Circ J. 2010; 74(11):2479–2500
[12]Fuster V, Rydén LE, Cannom DS, et al. American College of Cardiology Foundation/American Heart Association Task Force. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011; 123(10):e269–e367
[13]Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation. A report of the American College of Cardiology clinical expert consensus document task force. J Am Coll Cardiol. 2017; 69(7):871–898
[14]Eikelboom JW, Connolly SJ, Brueckmann M, et al. RE-ALIGN Investigators. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013; 369(13):1206–1214
[15]Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2017; 135(25):e1159–e1195
[16]Vahanian A, Alfieri O, Andreotti F, et al. ESC Committee for Practice Guidelines (CPG), Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012) the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012; 42(4):S1–S44
[17]Douketis JD, Spyropoulos AC, Kaatz S, et al. BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015; 373(9):823–833
[18]Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49(3):1600791
[19]Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation. 2009; 120(21):e169–e276
Appendices
Appendix 27.A Preoperative checklist.
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