The Patient History

Before undertaking any procedure, the physician must begin with a pertinent comprehensive health history and thorough understanding of the patient and their current health condition. Preexisting diagnoses, such as diabetes or hemophilia, may affect wound healing or bleeding.

Allergies to medication, tape, or preparation agents should be elicited along with any personal or family history of bleeding or thrombosis. Anticoagulant use, including aspirin, clopidogrel, warfarin, nonsteroidal anti-inflammatory drugs (NSAIDs), ticlopidine, dipyridamole, and fish oil may affect bleeding and hemostasis during any procedure. Short-acting NSAIDs should be held for 1 or 2 days before surgery based on their antiplatelet effect and drug half-life. Aspirin, dipyridamole, ticlopidine, and long-acting NSAIDs should be stopped 7 to 10 days before surgery if the benefit of improved hemostasis during the procedure outweighs the risk of complications from the underlying medical condition for which the medication is prescribed. Warfarin (Coumadin) should be stopped based on risk profiles. Low-risk patients with no thrombotic history who are taking anticoagulants for atrial fibrillation may have their warfarin stopped 3 to 4 days before surgery and may have no "bridging" heparin. If a patient has a high risk for thromboembolism, such as past pulmonary embolism, mechanical valve, or current treatment for deep vein thrombosis, a "bridge" with low-molecular-weight heparin or regular heparin should be given. Warfarin may be resumed immediately after surgery, and then the hepa-rin may be discontinued once the international normalized ratio (INR) is therapeutic (Singer et al., 2008b).

Aspirin and other antiplatelet medications may be resumed 24 hours after surgery. If the patient is high risk and receiving a superficial procedure, the physician should continue the blood-thinning agent and consider using local anesthesia with epinephrine. Local cautery, direct ligation of bleeding vessels, and direct pressure are used as needed for hemosta-sis. Fish oil taken with aspirin or warfarin may potentiate the antiplatelet effects (Ramsay et al., 2005).

A history of delayed healing or keloid (thick scar) formation should be elicited. A prior vasovagal event or fainting episode warrants preventive measures to reduce the potential risk of complications should a patient faint during or after a procedure.

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