Dermatology Question of the Week: Surgical Skills

A 55-year-old man with a history of anticoagulation therapy for atrial fibrillation is scheduled for an excision of a 1.5 cm basal cell carcinoma on his left arm. His medications include warfarin, with a recent INR of 2.5. The patient expresses concern about bleeding during the procedure. What is the most appropriate next step in management?
A. Discontinue warfarin 5 days before the procedure and bridge with low-molecular-weight heparin
B. Delay the procedure until warfarin is adjusted to achieve an INR of <1.5
C. Cancel the procedure and refer the patient to a cardiologist for anticoagulation management
D. Proceed with the procedure and use local hemostatic measures
Rationale:
This question evaluates the understanding of anticoagulation management in dermatologic surgery, emphasizing a balance between bleeding risk and thromboembolic risks. Most dermatologic procedures, including excisions, are low-risk for significant bleeding. Current literature supports performing minor procedures without altering anticoagulation. Avoiding unnecessary changes to anticoagulation can avoid increasing the risk for thromboembolic events.
Correct answer choice: D. Proceed with the procedure and use local hemostatic measures
Methods can be employed such as electrocautery or pressure dressings, to manage bleeding without altering warfarin therapy. This is the safest, most evidence-based approach. Local hemostatic measures are highly effective in managing bleeding during minor procedures, allowing the patient to maintain therapeutic anticoagulation.
Incorrect answer choices:
A. Discontinue warfarin 5 days before the procedure and bridge with low-molecular-weight heparin
Bridging is unnecessary for low-risk procedures and increases thromboembolic risk. This approach is reserved for high-risk procedures or patients with significant thromboembolic risk.
B. Delay the procedure until warfarin is adjusted to achieve an INR of <1.5
An INR of 2.5 is within the therapeutic range for atrial fibrillation. Reducing it to <1.5 unnecessarily increases thromboembolic risk without providing benefit for a low-risk dermatologic procedure.
C. Cancel the procedure and refer the patient to a cardiologist for anticoagulation management
This option delays treatment unnecessarily. Low-risk dermatologic procedures can be safely performed without anticoagulation adjustment or cardiology consultation.
Additional reading at Fitzpatrick's Dermatology Chapter 202: Perioperative Considerations in Dermatologic Surgery
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