Preoperative monitoring of warfarin in cutaneous surgery

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Abstract
Summary Background We report a patient who developed postoperative bleeding as a result of inadvertent excessive warfarin intake. We subsequently introduced a policy of checking the international normalization ratio (INR) 24 h before cutaneous surgery for all patients on warfarin. Objectives To review the perioperative INR and outcome of all patients on warfarin who had cutaneous surgery from January 1999 to June 2002 at the Department of Dermatology, Sunderland Royal Hospital. Methods A retrospective review was undertaken from patients' medical records. Results Sixty-eight patients (1·84% of total) underwent 85 skin procedures comprising 33 excisions, 16 punch biopsies, 15 curettages, 13 diagnostic biopsies, five shave biopsies, two Mohs micrographic surgical excisions and one delayed reconstruction. Repairs included 50 direct closures, five secondary intention healing, seven local flaps, two full-thickness skin grafts and 20 by electrocautery. Forty-five surgical procedures were undertaken with the INR checked on the day of surgery, 37 procedures within 24 h, and three within 2 days. The preoperative INR ranged from 1·1 to 3·4, median 2·5. There was no excess intraoperative or postoperative bleeding or haematoma for all patients. Conclusions Our experience supports the continued and safe use of warfarin for a wide variety of cutaneous surgical procedures with a preoperative INR of < 3·5. We recommend a routine INR before the procedure, preferably within 24 h.