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AntiCoagulation Management

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STEP 1: Determine if Anticoagulant Needs to be Stopped

Some minor procedures may proceed without interruption of anticoagulation.

Examples of Procedures Which May Proceed Without Interruption of Anticoagulation

  • Minor dental procedures (removal of 1-3 teeth)
  • Removal of minor skin lesions
  • Incision of superficial abscesses
  • Cataract surgery
  • Cystoscopy/ gastroscopy/ colonoscopy without biopsy
  • ERCP without sphincterotomy

Patients on warfarin should have their INR checked to exclude excessive anticoagulation.

Warfarinised patients undergoing dental procedures with an INR > 2.2 may benefit from tranexamic mouthwash.  See protocol in therapeutic guidelines

In patients taking rivaroxaban, dabigatran or apixaban, avoid undertaking the procedure during time of peak drug effect.

  • Rivaroxaban: 2-3 hours post ingestion
  • Dabigatran: 2 hours post ingestion
  • Apixaban: 2-3 hours post ingestion

Discuss with surgical team if there is uncertainty regarding the need to withhold anticoagulation.

STEP 2: Consider Benefit of Delaying Surgery

Patients at high thrombotic risk due to a transient cause may benefit from delay of surgery until the thrombotic risk has fallen. High thrombotic risk that will not reduce with time (eg mechanical heart valves) will not benefit from surgical delay. In patients with an urgent indication for surgery the risks and benefits of delay should be weighed.


Senior advice should be sought before postponement of planned surgery.

Recommended Minimum Duration of Anticoagulation Before Interruption for Surgery

Arterial Thromboembolism

At least ONE MONTH where possible

Venous Thromboembolism

At least THREE MONTHS where possible

Mechanical / Bioprosthetic Heart Valve Implantation

At least THREE MONTHS where possible

Recommended Minimum Duration of Anticoagulation Before Interruption for Surgery

Arterial Thromboembolism

At least ONE MONTH where possible

Venous Thromboembolism

At least THREE MONTHS where possible

Mechanical / Bioprosthetic Heart Valve Implantation

At least THREE MONTHS where possible

STEP 3: Assess Surgical Bleeding Risk

Consider the risks and consequences of bleeding for the specific procedure planned for this patient.

Minor residual anticoagulant effect may be acceptable in certain procedures, but dangerous in others.

Interventions with LOW Bleeding Risk

  • Endoscopy with biopsy
  • Prostate, breast or bladder biopsy
  • Non-coronary angiography
  • Pacemaker insertion
  • Laparoscopic cholecystectomy
  • Abdominal/ inguinal hernia repair
  • Arthroscopy
  • Carpal tunnel repair
  • Dilation and curettage
  • Skin cancer excision

Interventions with HIGH Bleeding Risk

  • Liver or kidney biopsy
  • Some endoscopic procedures:
    • Biliary sphincterotomy
    • Treatment of varices
  • Thoracic or abdominal surgery
  • major orthopaedic surgery
  • Cardiac Surgery
  • Neurosurgery
  • Cancer surgery
  • TURP

STEP 4: Determine Time to Cease Anticoagulant

Therapeutic Dose Anticoagulants
Warfarin

Withhold Before Surgery

Day Before Surgery, Check INR

If Vit K Given on Day Befoire Surgery,
Recheck INR Immediately Pre-Operatively

Stop Warfarin 5 Days Before Surgery

If INR still > 1.5, Give 1mg IV Vit K

If INR still > 1.5 (Neurosurgery 1.3), Give 30U/kg Prothrombinex

Active warfarin related bleeding may also warrant consideration of FFP

Pre-Operative Warfarin Management

Withhold Before Surgery

Stop Warfarin 5 Days Before Surgery

Day Before Surgery, Check INR

If INR still > 1.5, Give 1mg IV Vit K

If Vit K Given on Day Before Surgery,
Recheck INR Immediately Pre-Operatively

If INR still > 1.5 (Neurosurgery 1.3), Give 30U/kg Prothrombinex

Active warfarin related bleeding may also warrant consideration of FFP

Direct Oral AntiCoagulants

CLEARANCE OF DIRECT ACTING ORAL ANTICOAGULANTS IS RENAL DEPENDENT. CHECK CREATININE CLEARANCE ON A RECENT EUC

Creatinine Clearance > 50ml/min1

Period to Withhold Anticoagulant Before Surgery

Low Risk of Surgical Bleeding

High Risk of Surgical Bleeding

Neuraxial Procedure

Rivaroxaban
(Xarelto)

Withhold 24 hours
(Last dose Day -2)

Withhold 2-3 Days
(Last dose Day -3 or Day -4)

Withhold 3 Days
(Last dose Day -4)

Dabigatran
(Pradaxa)

CrCl ≥ 80: Withhold 24 hours
(Last dose Day -2)

CrCl 50-80: Withhold 24-48 hours
(Last dose Day -2 or Day -3)

CrCl ≥ 80: Withhold 2 Days
(Last dose Day -3)

CrCl 50-80: Withhold 2-3 Days
(Last dose Day -3 or Day -4)

CrCl ≥ 80: Withhold 3 Days
(Last dose Day -4)

CrCl 50-80: Withhold 4 Days
(Last dose Day -5)

Apixaban
(Eliquis)

Withhold 24 hours
(Last dose Day -2)

Withhold 2-3 Days
(Last dose Day -3 or Day -4)

Withhold 3 Days
(Last dose Day -4)

Creatinine Clearance > 50ml/min1

Period to Withhold Anticoagulant Before Surgery

Rivaroxaban
(Xarelto)

Low Risk of Surgical Bleeding

Withhold 24 hours
(Last dose Day -2)

High Risk of Surgical Bleeding

Withhold 2-3 Days
(Last dose Day -3 to Day -4)

Neuraxial Procedure

Withhold 3 days
(Last dose Day -4)

Dabigatran
(Pradaxa)

Low Risk of Surgical Bleeding

CrCl ≥ 80:
Withhold 24 hours
(Last dose Day -2)

CrCl 50-80:
Withhold 24-48 hours
(Last dose Day -2 to Day -3)

High Risk of Surgical Bleeding

CrCl ≥ 80:
Withhold 2 Days
(Last dose Day -3)

CrCl 50-80:
Withhold 2-3 Days
(Last dose Day -3 or Day -4)

Neuraxial Procedure

CrCl ≥ 80:
Withhold 3 Days
(Last dose Day -4)

CrCl 50-80:
Withhold 4 Days
(Last dose Day -5)

Apixaban
(Eliquis)

Low Risk of Surgical Bleeding

Withhold 24 Hours
(Last dose Day -2)

High Risk of Surgical Bleeding

Withhold 2-3 Days
(Last dose Day -3 to Day -4)

Neuraxial Procedure

Withhold 3 Days
(Last dose Day -4)

Creatinine Clearance 30-49ml/min1

Period to Withhold Anticoagulant Before Surgery

Low Risk of Surgical Bleeding

High Risk of Surgical Bleeding

Neuraxial Procedure

Rivaroxaban
(Xarelto)

Withhold 48 hours
(Last dose Day -3)

Withhold 3 Days
(Last dose Day -4)

Withhold 3 Days
(Last dose Day -4)

Dabigatran
(Pradaxa)

Withhold 2-3 Days
(Last dose Day -3 to Day -4)

Withhold 4 Days
(Last dose Day -5)

Withhold 5 Days
(Last dose Day -6)

Apixaban
(Eliquis)

Withhold 2 Days
(Last dose Day -3)

Withhold 3 Days
(Last dose Day -4)

Withhold 4 Days
(Last dose Day -5)

Creatinine Clearance > 30-49ml/min1

Period to Withhold Anticoagulant Before Surgery

Rivaroxaban
(Xarelto)

Low Risk of Surgical Bleeding

Withhold 48 hours
(Last dose Day -3)

High Risk of Surgical Bleeding

Withhold 3 Days
(Last dose Day -4)

Neuraxial Procedure

Withhold 3 Days
<(Last dose Day -4)

Dabigatran
(Apixaban)

Low Risk of Surgical Bleeding

Withhold 2-3 Days
(Last dose Day -3 to Day -4)

High Risk of Surgical Bleeding

Withhold 4 Days
(Last dose Day -5)

Neuraxial Procedure

Withhold 5 Days
(Last dose Day -6)

Apixaban
(Eliquis)

Low Risk of Surgical Bleeding

Withhold 2 Days
(Last dose Day -3)

High Risk of Surgical Bleeding

Withhold 3 Days
(Last dose Day -4)

Neuraxial Procedure

Withhold 4 Days
(Last dose Day -5)

Prophylactic Dose Anticoagulants

Last Dose PRIOR to Neuraxial Procedure

First Dose AFTER Neuraxial Procedure

Rivaroxaban
10mg PO Daily

Withhold 22-26 hours

If CrCl < 50 or dose > 10mg/day extend to 44-65 hours

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose rivaroxaban accidentally given while epidural still in, wait 22-26 hours before removing epidural

Dabigatran
150-220mg PO Daily

Withhold 34 hours

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose dabigatran accidentally given while epidural still in, wait 34-36 hours before removing epidural

Apixaban
2.5mg PO BD

if 2.5mg/day withhold 26-30 hours

If 5mg/day or Cr ≥ 133µmol/L and < 80yo or < 60kg
withhold 40-75 hours

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose apixaban accidentally given while epidural still in, wait 26-30 hours before removing epidural

PROPHYLACTIC Dose Enoxaparin
40mg SC Daily

Withhold 12 hours

Withhold 12 hours
Extend to 24 hours if traumatic puncture

Epidural can remain in situ during prophylactic LMWH provided dosing no more frequent then q24h

Withhold LMWH 12 hr before epidural removal
Wait 4 hours after epidural removal before LMWH dose


THERAPEUTIC Dose Enoxaparin
1mg/kg SC BD

Withhold 24 hours

For therapeutic dosing delay first post-operative dose until at least 24 hours after needle/ catheter placement. Subsequent LMWH dosing should occur at least 4 hours after catheter removal.

Note that therapeutic dose LMWH may be resumed 24 hours after low bleeding risk surgery, and 48-72 hours after high-bleeding risk surgery

Rivaroxaban

Prophylactic Dose

10mg PO Daily

Last Dose PRIOR to Neuraxial Procedure

(based on 2 drug half lives)

Withhold 22-26 hours

If CrCl < 50, extend to 44-65 hours

First Dose AFTER Neuraxial Procedure

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose rivaroxaban accidentally given while epidural still in, wait 22-26 hours before removing epidural

Dabigatran

Prophylactic Dose

150-220mg PO Daily

Last Dose PRIOR to Neuraxial Procedure

(based on 2 drug half lives)

Withhold 36 hours

If Renal Function Normal

First Dose AFTER Neuraxial Procedure

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose dabigatran accidentally given while epidural still in, wait 34-36 hours before removing epidural

Apixaban

Prophylactic Dose

2.5mg PO BD

Last Dose PRIOR to Neuraxial Procedure

(based on 2 drug half lives)

if 2.5mg/day:
withhold 26-30 hours

If 5mg/day
or
Cr ≥ 133µmol/L and < 80yo or < 60kg:
withhold 40-75 hours

First Dose AFTER Neuraxial Procedure

Withhold 6 hours after neuraxial procedure
Extend to 24 hours if traumatic puncture

Remove epidural catheter at least 6 hours prior to first dose

If prophylactic dose apixaban accidentally given while epidural still in, wait 26-30 hours before removing epidural

PROPHYLACTIC Dose Enoxaparin

Prophylactic Dose

40mg SC Daily

Last Dose PRIOR to Neuraxial Procedure

(based on 2 drug half lives)

Withhold 12 hours

First Dose AFTER Neuraxial Procedure

Withhold 12 hours
Extend to 24 hours if traumatic puncture

Epidural OK provided dosing no more frequent than q24h
Withhold LMWH 12 hr before epidural removal

Wait 4 hours after epidural removal before LMWH dose

THERAPEUTIC Dose Enoxaparin

Therapeutic Dose

1mg/kg SC BD

Last Dose PRIOR to Neuraxial Procedure

Withhold 24 hours

First Dose AFTER Neuraxial Procedure

For therapeutic dosing delay first post-operative dose until at least 24 hours after needle/ catheter placement. Subsequent LMWH dosing should occur at least 4 hours after catheter removal.

Note that therapeutic dose LMWH may be resumed 24 hours after low bleeding risk surgery, and 48-72 hours after high-bleeding risk surgery

Neuraxial Anaesthesia and Anticoagulation

Neuraxial Anaesthesia / Spinal puncture under the effect of anticoagulation carries a risk of spinal or epidural haematoma and long term paralysis. Drug pharmacokinetics should be taken into consideration, and appropriate laboratory tests considered.

Factors that may increase this risk include:

  • use of indwelling epidural catheters
  • concomitant use of other drugs affecting haemostasis (NSAIDs, platelet inhibitors, other anticoagulants)
  • a history of traumatic or repeated epidural or spinal punctures
  • a history of spinal deformity or spinal surgery

2018 ASRA Guidelines allow prophylactic dose enoxaparin to be administered while an epidural catheter remains in situ, provided that enoxaparin is dosed no more frequently than once every 24 hours. Epidurals should be removed prior to commencement of anticoagulation with BD enoxaparin, therapeutic dose enoxapain, or a direct oral anticoagulant at any dose

STEP 5: Consider Bridging Anticoagulation

Bridging and the New Oral Anticoagulants
Bridging and the New Oral Anticoagulants (rivaroxaban, dabigatran, apixaban)
Bridging and the New Oral Anticoagulants
DUE TO THEIR RELATIVELY RAPID OFFSET AND ONSET OF ACTION, INTERRUPTION OF DIRECT ORAL ANTICOAGULANTS DOES NOT USUALLY REQUIRE BRIDGING.

Consider Bridging Anticoagulation in Patients on DOACs if:

Pre-Operatively

Pre-Operatively

  1. In patients with particularly high thromboembolic risk


Note that the newer anticoagulants are contraindicated for use in patients with prosthetic heart valves. These patients should be anticoagulated with warfarin.

  1. Where prolonged interruption of oral intake is anticipated (ie ileus)
  2. Where a high risk of bleeding favours initial anticoagulation with a more readily reversible agent (such as UFH)
Bridging for Patients on Warfarin
Atrial Fibrillation

PATIENTS ANTICOAGULATED FOR ATRIAL FIBRILLATION SHOULD BE RISK STRATIFIED ACCORDING TO THEIR THROMBOEMBOLIC RISK

  • Patients with Valvular Disease or Prior CVA/TIA are always considered High Risk
  • Other patients may be stratified with the CHA2DS2–VASc Score

Risk Criteria

Pre-Operative Bridging

Post-Operative Bridging

High Risk

  1. Associated Valvular Heart Disease
  2. History of Arterial Thromboembolism
  3. CHA2DS2-VASc: 7-9

Heparin Infusion
or
Therapeutic Dose Enoxaparin

Heparin Infusion
or
Therapeutic Dose Enoxaparin

commence within 12-24 hours if adequate surgical haemostasis

Moderate Risk

CHA2DS2-VASc: 5-6

Bridging Usually Not Required

Low Risk

CHA2DS2-VASc: 0-4

No Bridging Required

High Risk

Risk Criteria

  1. Associated Valvular Heart Disease
  2. History of Arterial Thromboembolism
  3. CHA2DS2-VASc: 7-9

Pre-Operative Bridging

Heparin Infusion
or
Therapeutic Dose Enoxaparin

Post-Operative Bridging

Heparin Infusion
or
Therapeutic Dose Enoxaparin

commence within 12-24 hours if adequate surgical haemostasis

Moderate Risk

Risk Criteria

CHA2DS2-VASc:
5-6

Pre-Operative Bridging

Bridging Usually Not Required

Post-Operative Bridging

Low Risk

Risk Criteria

CHA2DS2-VASc:
0-4

Pre-Operative Bridging

No Bridging Required

Post-Operative Bridging

Mechanical Heart Valves (and Bioprosthetic Heart Valves within 1st Three Months)

Pre-Operative Bridging

Post-Operative Bridging

Patients at Low Risk of Thrombosis
Bileaflet mechanical aortic valve
and
No Risk Factors*

Withhold warfarin 48‐72 hours pre procedure, and allow INR to fall < 1.5

Restart warfarin 24 hours post-procedure

Heparin Bridging Usually Not Required in This Group
Discussion with patient’s cardiologist is recommended

Patients at High Risk of Thrombosis
Mechanical Mitral Valve
or
any Risk Factors*

Heparin Infusion ceased 6‐8 hours pre‐operatively

Heparin Infusion commenced as soon as bleeding risk acceptable

Risk Factors: Mitral or Tricuspid Valve replacement, More than one mechanical valve, Atrial Fibrillation, Previous Thromboembolism, Left Ventricular Dysfunction, Hypercoagulable Condition, Older‐generation Thrombogenic Valves (ball and cage, tilting disc)

Patients at Low Risk of Thrombosis
Bileaflet mechanical aortic valve
and
No Risk Factors*

Pre-operative Bridging

Withhold warfarin 48‐72 hours pre procedure, and allow INR to fall < 1.5

Post-operative Bridging

Restart warfarin 24 hours post-procedure

Heparin Bridging Usually Not Required in This Group
Discussion with patient’s cardiologist is recommended

Patients at High Risk of Thrombosis
Mechanical Mitral Valve
or
any Risk Factors*

Pre-operative Bridging

Heparin Infusion ceased 6‐8 hours pre‐operatively

Pre-operative Bridging

Heparin Infusion commenced as soon as bleeding risk acceptable

Risk Factors: Mitral or Tricuspid Valve replacement, More than one mechanical valve, Atrial Fibrillation, Previous Thromboembolism, Left Ventricular Dysfunction, Hypercoagulable Condition, Older‐generation Thrombogenic Valves (ball and cage, tilting disc)

Venous Thromboembolism

Pre-Operative Bridging

Post-Operative Bridging

VTE within ONE month of surgery which cannot be delayed

Heparin Infusion
or
Therapeutic Dose Enoxaparin

Heparin Infusion
or
Therapeutic Dose Enoxaparin
commence within 12-24 hours if adequate surgical haemostasis

Consider IVC Filter insertion in selected cases. Consult Haematology.

VTE within 2-3 months of surgery which cannot be delayed

Prophylactic Dose Enoxaparin

Heparin Infusion
or
Therapeutic Dose Enoxaparin
commence within 12-24 hours if adequate surgical haemostasis

VTE more than 3 months before surgery

Prophylactic Dose Enoxaparain

Prophylactic Dose Enoxaparain

VTE within ONE month of surgery which cannot be delayed

Pre-Operative Bridging

Heparin Infusion

or

Therapeutic Dose Enoxaparin

Post-Operative Bridging

Heparin Infusion

or

Therapeutic Dose Enoxaparin

commence within 12-24 hours if adequate surgical haemostasis

Consider IVC Filter insertion in selected cases. Consult Haematology.

VTE within 2-3 months of surgery which cannot be delayed

Pre-Operative Bridging

Prophylactic Dose Enoxaparain

Post-Operative Bridging

Heparin Infusion

or

Therapeutic Dose Enoxaparin

commence within 12-24 hours if adequate surgical haemostasis

VTE more than 3 months before surgery

Pre-Operative Bridging

Prophylactic Dose Enoxaparain

Post-Operative Bridging

Prophylactic Dose Enoxaparain

Arterial Thromboembolism (CVA/ TIA/ Acute Embolic Limb Ischaemia/ Systemic Emboli)

Pre-Operative Bridging

Post-Operative Bridging

ATE within ONE month of surgery which cannot be delayed

Heparin Infusion
or
Therapeutic Dose Enoxaparin

Heparin Infusion
or
Therapeutic Dose Enoxaparin
commence within 12-24 hours if adequate surgical haemostasis

ATE more than a month before surgery

Prophylactic Dose Enoxaparin

Prophylactic Dose Enoxaparin

ATE within ONE month of surgery which cannot be delayed

Pre-Operative Bridging

Heparin Infusion

or

Therapeutic Dose Enoxaparin

Post-Operative Bridging

Heparin Infusion

or

Therapeutic Dose Enoxaparin

commence within 12-24 hours if adequate surgical haemostasis

ATE more than a month before surgery

Pre-Operative Bridging

Prophylactic Dose Enoxaparain

Post-Operative Bridging

Prophylactic Dose Enoxaparain

STEP 6: Determine Bridging Anticoagulant Dose

Unfractioned Heparin (UFH) Infusion
Pre-Operatively

Commence Heparin once INR < 2.0 (for patients bridging from warfarin).

Confirm normal APTT prior to commencement of heparin

Check APTT after 6 hours and adjust infusion rate according to hospital protocol

Post-Operatively

Discuss with surgical team once operation complete to determine desired starting time and whether loading dose desired.

Heparin infusion should be recommenced at rate determined during pre‐operative heparinisation.

Omit loading dose if preferred by surgical team.

If on warfarin commence at patients usual dose on evening of surgery. Overlap warfarin and heparin therapy for at least 5 days and until INR is therapeutic for > 2 days prior to ceasing heparin.

Therapeutic Heparin (UFH) Infusion
Pre-Operatively

Bridging Therapy with THERAPEUTIC dose enoxaparin should begin once INR is sub‐therapeutic. This will typically be around 36 hours after ceasing warfarin and 3 days prior to surgery.

Creatine Clearance > 30ml/min

Creatine Clearance 10-30ml/min

Creatine Clearance < 10ml/min

Enoxaparin 1mg/kg SC BD
(max 120mg BD)
or
Enoxaparin 1.5mg/kg SC once daily
(max 180mg)

Enoxaparin 1mg/kg once daily

Use IV Unfractionated Heparin

In patients ≥ 120kg BD Enoxaparin dosing is preferable to single daily dosing (ie 120mg BD rather than 180mg daily)

Creatine Clearance > 30ml/min

Enoxaparin 1mg/kg SC BD
(max 120mg BD)
or
Enoxaparin 1.5mg/kg SC once daily
(max 180mg)

Creatine Clearance 10-30ml/min

Enoxaparin 1mg/kg once daily

Creatine Clearance < 10ml/min

Use IV Unfractionated Heparin

In patients ≥ 120kg BD Enoxaparin dosing is preferable to single daily dosing (ie 120mg BD rather than 180mg daily)

Therapeutic dose enoxaparin should be ceased 24 hours prior to operation.

Post-Operatively

Discuss with surgical team once operation complete to determine desired starting time.

If on warfarin commence at patients usual dose on evening of surgery. Overlap warfarin and enoxaparin therapy for at least 5 days and until INR is therapeutic prior to ceasing heparin.

Prophylactic Heparin (UFH) Infusion
Pre-Operatively

Bridging therapy with prophylactic enoxaparin should begin once INR is sub‐therapeutic. This will typically be around 36 hours after ceasing warfarin and 3 days prior to surgery.

Enoxaparin Thromboprophylaxis Dosing in Obesity7

Weight

< 50kg

50 - 100kg

100 - 150kg

> 150kg

Dose

20mg daily

40mg daily

40mg BD

60mg BD

Enoxaparin Thromboprophylaxis Dosing in Obesity7

Weight

Dose

< 50kg

20mg daily

50 - 100kg

40mg daily

100 - 150kg

40mg BD

> 150kg

60mg BD

Prophylactic dose enoxaparin should be ceased 12 hours prior to operation.

Post-Operatively

Discuss with surgical team once operation complete to determine desired starting time. Typically 6‐12 hours post surgery, increased to 24 hours in patients at high risk of peri‐operative bleeding.

If on warfarin commence at patients usual dose on evening of surgery.

Overlap warfarin and enoxparin therapy for at least 5 days and until INR is therapeutic for > 2 days prior to ceasing heparin.

STEP 7: Recommence Oral Anticoagulation Post‐Operatively

The timing for recommencement of oral anticoagulation post‐operatively is a surgical decision, and takes into account the risk and
consequences of surgical site bleeding, balanced with the thromboembolic risk.

Suggested Period to Withhold Anticoagulant After Surgery

Low Risk of Surgical Bleeding

High Risk of Surgical Bleeding

Important Considerations

Rivaroxaban

Dabigatran

Apixaban

Withhold
1 Day Post-op

Withhold
2 Days Post-op

Full anticoagulation effect established within hours, eliminates need for post‐operative bridging anticoagulation.

However, difficult to reverse anticoagulation effect if surgical bleeding develops.

Warfarin

Plan to Recommence Warfarin
12-24 Hours Post-op

Delayed onset of effect may require bridging therapy
(See step 5)

Suggested Period to Withhold Anticoagulant After Surgery

Rivaroxaban/ Dabigatran/ Apixaban

Low Risk of Surgical Bleeding

Withhold
1 Day Post-op

High Risk of Surgical Bleeding

Withhold
2 Days Post-op

Important Considerations
Full anticoagulation effect established within hours, eliminates need for post‐operative bridging anticoagulation.

However, difficult to reverse anticoagulation effect if surgical bleeding develops.

Warfarin

Plan to Recommence Warfarin
12-24 Hours Post-op

Important Considerations
Delayed onset of effect may require bridging therapy
(See step 5)

References

  1. Guidelines on perioperative management of anticoagulant and antiplatelet agents - NSW Clinical Excellence Commission 2018
  2. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy - ASRA - 4th Edition 2018
  3. Neuraxial Anesthesia and Peripheral Nerve Blocks in Patients on Anticoagulants - NYSORA
  4. How To Bridge Management Of Anticoagulation In Patients With Mechanical Heart Valves Undergoing Noncardiac Surgical Procedures - J Thoracic And Cardiovasc Surgery 2019
  5. Bridging Anticoagulation With Mechanical Heart Valves - Current Guidelines And Clinical Decisions - Curr Cardiol Reports 2020
  6. Periprocedural antithrombotic management for lumbar puncture - Association of British Neurologists clinical guideline - BMJ 2018
  7. Perioperative Management of the Obese Surgical Patient - AAGBI 2015
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