7 - Surgery - Warfarin bridging therapy Flashcards
How many days pre-surgery should you stop warfarin
5 days
How many days pre-surgery should you stop warfarin
5 days
What should be done with warfarin in emergency surgery
Vit K reversal (4-24 hours)
or
Beriplex reversal (1 hour) - this is a dried prothrombin complex containing variable amounts of clotting factors
What INR is required for surgery to proceed
What is considered a low VTE risk requiring no pre-op LMWH
CHA2DS2VASc 0-2 and not prior stroke/TIA
Single VTE >12 months ago
No risk factors
What is considered moderate VTE risk
CHA2DS2VASc 3-4
Recurrent VTE, or VTE in past 3-12 months
Active cancer
What should be done pre-op for moderate VTE risk?
Start therapeutic dose LMWH two days after stopping warfarin
What is considered high VTE risk?
CHA2DS2VASc score 5-6 with any prior stroke/VTE
Recent stroke/TIA/VTE
Mitrial stroke/valve prosthesis
What should be done for patients with high VTE risk pre-op?
LMWH two days after stopping warfarin OR
admit for UFH infusion once INR
What should be done with warfarin in emergency surgery
Vit K reversal (4-24 hours)
or
Beriplex reversal (1 hour) - this is a dried prothrombin complex containing variable amounts of clotting factors
What INR is required for surgery to proceed
What is considered a low VTE risk requiring no pre-op LMWH
CHA2DS2VASc 0-2 and not prior stroke/TIA
Single VTE >12 months ago
No risk factors
What is considered moderate VTE risk
CHA2DS2VASc 3-4
Recurrent VTE, or VTE in past 3-12 months
Active cancer
What should be done pre-op for moderate VTE risk?
Start therapeutic dose LMWH two days after stopping warfarin
What is considered high VTE risk?
CHA2DS2VASc score 5-6 with any prior stroke/VTE
Recent stroke/TIA/VTE
Mitrial stroke/valve prosthesis
What should be done for patients with high VTE risk pre-op?
LMWH two days after stopping warfarin OR
admit for UFH infusion once INR
What should be done for patients with high VTE risk pre-op?
LMWH two days after stopping warfarin OR
admit for UFH infusion once INR
What is the advantage of using a heparin before surgery instead of warfarin
shorter half life so patients can be fully anticoagulated before surgery
When should the last dose be given before surgery:
Warfarin
LMWH
UFH
Warfarin - six days before
LMWH - (morning the day before) do not give on morning of surgery
UFH - six hours before
when do we want to start warfarin after surgery?
What should we do until then for
low VTE risk
moderate/high risk
v high risk (mechanical heart vales)
ASAP - depending on bleed risk
Cover until INR is therapeutic:
LOW RISK - prophylactic LMWH
MODERATE/HIGH - treatment LMWH
MECHANICAL HEART VALVE - IV UFH
in practice when is warfarin started after surgery?
not the evening of surgery as fears that they might need surgery again.
BUT ASAP after that.
must be on warfarin for discharge.
must have INR in range before stopping heparin
in practice when is warfarin started after surgery?
not the evening of surgery as fears that they might need surgery again.
BUT ASAP after that.
must be on warfarin for discharge.
must have INR in range before stopping heparin
If a prohplactic dose of LMWH is required post-op when do we start this?
LOW BLEED RISK - eve post-op
HIGH BLEED RISK - 24-48h post-op
If a theraputic dose of LMWH is required post-op when do we start this?
LOW BLEED RISK - 24-48h post-op
HIGH BLEED RISK - start a prophylatic dose 24-48h, then a theraputic dose 48-72 hours post-op
