When to Stop Blood Thinner Before a Procedure?

I review several dozen medication lists each week.  I do so in my office visits as well as prior to performing procedures.  This routine task is not always as easy it seems.  One would think that this would be a breeze in the era of the electronic medical record (EMR). But it’s not.  On a regular basis there are inaccuracies.  There may be medicines listed that the patient is no longer taking.  More challenging, there may be medicines being taken that do not appear on the list.  Many patients are on more than 10 medicines.  Medication dosages often change and I often have to hope that the recorded dosages are accurate.  And, as every physician knows, patients are often unaware of the purpose or doses of some of their medicines.

I regularly query patients if they are taking a particular medicine on the list and often they simply do not know.

The medical profession has made progress is closing these gaps.  For example, when patients are discharged from the hospital, the care team engages in a process called medical reconciliation when a final and accurate list of discharge medicines are recorded and reviewed with the patient.

Gastroenterologists like me are always keenly interested if a patient is taking a blood thinner.  When I formerly cared for hospitalized patients with internal bleeding, often it was this class of medicines that caused the hemorrhage.  As expected, thin blood can lead to unwanted bleeding.

Gastroenterologists are keenly interested if a patient taking a blood thinner is to undergo a procedure such as a colonoscopy or surgery.  In most cases, these medicines are temporarily held prior to the procedure in order to minimize the risk of a bleeding complication from removing polyps, for example. Holding the blood thinner should not be casually undertaken as there are instances when doing so might be risky.  In these situations, it is important for the medical team to collaborate so that the patient can be advised of the available options.  Stopping a blood thinner, even temporarily, has some risk to these patients, although the risk is usually quite small.. A decision to hold a blood thinner requires a risk/benefit analysis and discussion.

Hmmm, when did I stop the blood thinner?

And what follows below is a personal frustration I have had with this issue.

When I schedule a procedure on a patient I am seeing in my office whose blood thinner will be held for a number of days in advance, I inform that patient that on procedure day, my nurses and I will ask precisely when the blood thinner was stopped.  Despite this caveat, often patients arrive uncertain  when the blood thinner was stopped  This is always vexing for us as we can’t be certain that the blood thinner has left his system.  This might curtail our activities inside the colon.

In the perfect world, which we not the planet we live in, every patient would carry with him an accurate and updated medication list.  Wasn't the EMR supposed to be the fix?  Yet another promise that the EMR zealots did not keep.

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