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Module: Peri-operative Care in the Rural Setting

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A bridge too far?


Samantha Iannella, MBBS VI
Stefan Court-Kowalski, MBBS V

University of Adelaide

Associate Professor Michael Wan
Head of Basic and Clinical Science (BCS) Domain
Associate Professor, Assessment. Medical Education Unit
School of Medicine, Sydney
The University of Notre Dame Australia


This case describes the principles surrounding warfarin use and bridging therapy, the advantages and disadvantages of the new oral anticoagulants (NOACs) and their reversal.

Pre-operative optimisation refers to identifying and managing patient-specific factors to maximise their fitness for the anaesthetic and the operation. Multidisciplinary input is often required, especially when the pursuit of clinical stability involves controlling multiple comorbidities, altering medications, counteracting physical deconditioning, correcting imbalances in fluid and nutritional status, and more.

One of the risks to be anticipated and mitigated before surgery is the risk of bleeding. This is an especially important consideration in patients with abnormal coagulation, the most common example being a patient on anticoagulant medication. The case that follows focuses on the pre-operative management of the warfarinised patient and the place of the newer alternative anticoagulants.

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