7 - Surgery - Warfarin bridging therapy

Question 1

How many days pre-surgery should you stop warfarin

Answer 1

5 days

Question 2

How many days pre-surgery should you stop warfarin

Answer 2

5 days

Question 3

What should be done with warfarin in emergency surgery

Answer 3

Vit K reversal (4-24 hours)
or
Beriplex reversal (1 hour) - this is a dried prothrombin complex containing variable amounts of clotting factors

Question 4

What INR is required for surgery to proceed

Question 5

What is considered a low VTE risk requiring no pre-op LMWH

Answer 5

CHA2DS2VASc 0-2 and not prior stroke/TIA

Single VTE >12 months ago

No risk factors

Question 6

What is considered moderate VTE risk

Answer 6

CHA2DS2VASc 3-4

Recurrent VTE, or VTE in past 3-12 months

Active cancer

Question 7

What should be done pre-op for moderate VTE risk?

Answer 7

Start therapeutic dose LMWH two days after stopping warfarin

Question 8

What is considered high VTE risk?

Answer 8

CHA2DS2VASc score 5-6 with any prior stroke/VTE

Recent stroke/TIA/VTE
Mitrial stroke/valve prosthesis

Question 9

What should be done for patients with high VTE risk pre-op?

Answer 9

LMWH two days after stopping warfarin OR

admit for UFH infusion once INR

Question 10

What should be done with warfarin in emergency surgery

Answer 10

Vit K reversal (4-24 hours)
or
Beriplex reversal (1 hour) - this is a dried prothrombin complex containing variable amounts of clotting factors

Question 11

What INR is required for surgery to proceed

Question 12

What is considered a low VTE risk requiring no pre-op LMWH

Answer 12

CHA2DS2VASc 0-2 and not prior stroke/TIA

Single VTE >12 months ago

No risk factors

Question 13

What is considered moderate VTE risk

Answer 13

CHA2DS2VASc 3-4

Recurrent VTE, or VTE in past 3-12 months

Active cancer

Question 14

What should be done pre-op for moderate VTE risk?

Answer 14

Start therapeutic dose LMWH two days after stopping warfarin

Question 15

What is considered high VTE risk?

Answer 15

CHA2DS2VASc score 5-6 with any prior stroke/VTE

Recent stroke/TIA/VTE
Mitrial stroke/valve prosthesis

Question 16

What should be done for patients with high VTE risk pre-op?

Answer 16

LMWH two days after stopping warfarin OR

admit for UFH infusion once INR

Question 17

What should be done for patients with high VTE risk pre-op?

Answer 17

LMWH two days after stopping warfarin OR

admit for UFH infusion once INR

Question 18

What is the advantage of using a heparin before surgery instead of warfarin

Answer 18

shorter half life so patients can be fully anticoagulated before surgery

Question 19

When should the last dose be given before surgery:

Warfarin
LMWH
UFH

Answer 19

Warfarin - six days before
LMWH - (morning the day before) do not give on morning of surgery
UFH - six hours before

Question 20

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)

Answer 20

ASAP - depending on bleed risk

Cover until INR is therapeutic:
LOW RISK - prophylactic LMWH
MODERATE/HIGH - treatment LMWH

MECHANICAL HEART VALVE - IV UFH

Question 21

in practice when is warfarin started after surgery?

Answer 21

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

Question 22

in practice when is warfarin started after surgery?

Answer 22

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

Question 23

If a prohplactic dose of LMWH is required post-op when do we start this?

Answer 23

LOW BLEED RISK - eve post-op

HIGH BLEED RISK - 24-48h post-op

Question 24

If a theraputic dose of LMWH is required post-op when do we start this?

Answer 24

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