Surgery for patients on warfarin

CARING FOR THE PEOPLE OF NORTHEAST MICHIGAN GREAT LAKES HEART CENTER OF ALPENA
HOME ATRIAL FIBRILLATION DVT VALVULAR HEART DISEASE SURGERY DOSING
The information presented here is meant as a guide or reference only. As always clinical judgement should always be exercised in dealing with individual patients.
Procedures that may not require discontinuation of warfarin Endoscopic procedures upper endoscopy with or without biopsy sigmoidoscopy or colonoscopy with or without biopsy endoscopic retrograde cannulation of the pancreatic duct without sphincterotomy push small bowel endoscopy Opthalmologic procedures cataract extraction trabeculectomy Dental procedures hygeine treatment uncomplicated extraction periodontal therapy restorations endodontics prosthetics Dermatologic procedures excisions Mohs surgery		Procedures that require discontinuation of warfarin Endoscopic procedures polypectomy laser ablation or coagulation endoscopic sphincterotomy esophageal dilatation PEG tube placement treatment of varices Opthalmologic procedures vitreoretinal surgery lid, lacrimal and orbital surgery Dental procedures complicated extractions gingival surgery alveolar surgery Dermatologic procedures hair transplantation blepharoplasty
Conditions requiring bridging with heparin Hypercoagulable (e.g. antiphospholipid antibody antithrombin III deficiency homozygous factor V Leiden mutation protein C or S deficiency, Venous or arterial thromboembolism in preceding 3 months Atrial fibrillation with: rheumatic heart disease history of thromboembolism mechanical heart valve (in any position) Intracardiac thrombus on echocardiography Recently placed mechanical prosthesis Older mechanical prosthesis (ball-cage or single disc) in the mitral position		Intermediate risk conditions requiring bridging on a case by case basis History of multiple strokes or TIA's without risk factors Newer mechanical valves in the mitral position Older mechanical valve in the aortic position Atrial fibrillation with risk factors but no history of previous embolic events Venous thromboembolism in the previous 6 months
Conditions that do not requiring bridging with heparin Newer prosthetic valves in the aortic position Atrial fibrillation without risk factors for embolism History of remote (>6 months) venous thromboembolism Carotid atherosclerosis without recurrent strokes or TIA's		Management of anticoagulation prior to surgery Stop warfarin 5 days prior to surgery. Most procedures can be performed with an INR of 1.5 or less. Bridging regimens using low molecular weight heparin Enoxaparin 1mg/kg SQ every 12 hrs. or Enoxaparin 1.5 mg/kg SQ every 24 hrs. or Daltaparin 120 U/ SQ every 12 hrs. or Daltaparin 200 U/ SQ every 24 hrs. or Tinzaparin 175 U/kg every 24 hrs. Stop LWMH 24 hrs. prior to surgery Restart LMWH 24 hrs. after surgey Restart previous maintenance warfarin dose after surgery Stop LMWH when INR is 2-3 on 2 consecutive days
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