Guideline and Protocols
Warfarin Therapy – Management During Invasive Procedure
and Surgery
Effective Date: October 1, 201...
Glimpses of warfarin
•
•
•
•
•
•
•
•
•

Coumarin derivatives
Inhibit Vit-K dependent carboxylation
Effective deficiency of...
Indications
• INR 2.5
–
–
–
–
–
–
–
–
–

Prevention and treatment of VTE
Arterial embolism
AF with specific stroke risk fa...
Treatment Recommendation for
Persistently APA-positive Individuals
Clinical circumstances

Recommendation

Asymptomatic

N...
Contraindications
• Recent surgery, specially eye or CNS
• Pre-existing haemorrhagic state
- liver disease
- haemophilia
-...
Bleeding risk score
•
•
•
•

Age >65 yrs – 1
Previous GI bleed – 1
Previous stroke – 1
Medical illness – 1
- recent MI
- r...
Therapeutic Measures for Reversal of
Warfarin Therapy
• Vitamin K
• Virally inactivated plasma-derived concentrate
• Froze...
Vitamin K
•
•
•
•
•
•
•

IV – fastest/most reliable
IM/SC - should be avoided
Procedure >24hrs – IV=PO
Useful post-operati...
Virally inactivated plasma-derived
concentrate
•
•
•
•
•

Rapid reversal
One dose – duration 6 hrs
Factors II, VII, IX, X,...
Frozen plasma
• Short duration – 4 hrs

• Rapid reversal
• Slight risk of infectious agent transmission
• Available in lar...
Consideration for Perioperative
Anticoagulation
• Acceptable INR for surgery
• Risk of bleeding
• Risk of thrombosis and n...
Acceptable INR for Surgery
• Always discuss surgeon/anesthesiologist

• INR <1.5 generally acceptable, except:
- neurosurg...
Risk of bleeding
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Type of procedure
Discontinuation of warfarin/ high risk of bleeding
- body ...
Risk of thrombosis and need for periprocedural bridging therapy
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Risk of thrombosis
from pre...
Management based on risk of thrombosis
• Low risk
•
- discontinue warfarin 5 days prior to surgery (-6)
•
- INR day before...
Timing of procedure
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Surgery should be elective if possible
If fixed duration anticoagulatio...
Timing of procedure – contd.
• Elective surgery with planned anticoagulant reversal
•
5-6 days warfarin free
•
consider LM...
Type of anesthesia
•
•
•
•
•
•
•
•
•
•
•
•

LA/GA safe to a patient on warfarin
Neuraxial blocks should not be performed
-...
intervention

Timing of surgery
elective

Urgent >24hrs

Urgent
24hrs

6-

Urgent < 6 hrs

Discontinue
warfarin

5days pri...
Risk of thrombosis
Low risk

High risk

Pre operative

Proceed to surgery <1.5

Elective- LMWH on day -3
Discontinue 24hrs...
“The darkest places in hell are reserved for those,
who maintain their neutrality in times of moral crisis.”
-Dante

Thank...
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Warferin guideline in oper........

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Warferin guideline in oper........

  1. 1. Guideline and Protocols Warfarin Therapy – Management During Invasive Procedure and Surgery Effective Date: October 1, 2010. Advisory committee British Columbia Medical Association Dr. Tarek Mahmood FCPS(medicine), MD, Rheumatology ( phase – B) BSMMU
  2. 2. Glimpses of warfarin • • • • • • • • • Coumarin derivatives Inhibit Vit-K dependent carboxylation Effective deficiency of factor II, VII, IX, X Monitored by INR >3 days to be effective Narrow therapeutic window Metabolism affected by many factor Major bleeding - 1%/year Fatal haemorrhage 0.25%/year
  3. 3. Indications • INR 2.5 – – – – – – – – – Prevention and treatment of VTE Arterial embolism AF with specific stroke risk factors Mobile mural thrombus/ post MI Extensive anterior MI DCM Cardioversion Ischemic stroke in APS MS/MR with AF • INR 3.5 – Recurrent venous thrombosis whilst on warfarin – Mechanical prosthetic cardiac valve
  4. 4. Treatment Recommendation for Persistently APA-positive Individuals Clinical circumstances Recommendation Asymptomatic No treatment Venous thrombosis Warfarin INR 2.5 - indefinitely Arterial thrombosis Warfarin INR 2.5 - indefinitely Recurrent thrombosis Warfarin INR 3-4 +/- aspirin Pregnancy: First pregnancy No treatment Single pregnancy loss <10wk No treatment 1 Fetal/3 embryonic losses/ no thrombosis Prophylactic heparin + low dose aspirin discontinue 6-12 wk postpartum Thrombosis regardless of pregnancy history Therapeutic heparin or low dose aspirin warfarin postpartum Thrombocytopenia: >50,000/cc No treatment <50,000/cc Prednisolone, IVIG
  5. 5. Contraindications • Recent surgery, specially eye or CNS • Pre-existing haemorrhagic state - liver disease - haemophilia - thrombocytopenia • Pre-existing structural lesions - peptic ulcer • Recent cerebral haemorrhage • Uncontrolled HTN • Cognitive impairment • Frequent falls in old age
  6. 6. Bleeding risk score • • • • Age >65 yrs – 1 Previous GI bleed – 1 Previous stroke – 1 Medical illness – 1 - recent MI - renal failure - anemia - DM • Score: 0 = 3% 1-2 = 12% 3- 4 = 40%
  7. 7. Therapeutic Measures for Reversal of Warfarin Therapy • Vitamin K • Virally inactivated plasma-derived concentrate • Frozen plasma
  8. 8. Vitamin K • • • • • • • IV – fastest/most reliable IM/SC - should be avoided Procedure >24hrs – IV=PO Useful post-operatively Excessive dose – difficulty with re-anticoagulation Effect on INR 8-12hrs Doses: - oral 1-2 mg - IV 5mg/50cc NS/30 mins
  9. 9. Virally inactivated plasma-derived concentrate • • • • • Rapid reversal One dose – duration 6 hrs Factors II, VII, IX, X, protein C, protein S Must with IV vit K Indications - active serious bleeding - surgery next 6 hrs • Contra indication - heparin induced thrombocytopenia - hepatic insufficiency
  10. 10. Frozen plasma • Short duration – 4 hrs • Rapid reversal • Slight risk of infectious agent transmission • Available in large center
  11. 11. Consideration for Perioperative Anticoagulation • Acceptable INR for surgery • Risk of bleeding • Risk of thrombosis and need for peri-procedural bridging therapy • Management based on risk of thrombosis • Timing of procedure • Type of anesthesia
  12. 12. Acceptable INR for Surgery • Always discuss surgeon/anesthesiologist • INR <1.5 generally acceptable, except: - neurosurgery - ocular surgery - spinal anesthesia - epidural analgesia
  13. 13. Risk of bleeding • • • • • • • • • • • • • • Type of procedure Discontinuation of warfarin/ high risk of bleeding - body cavity ( thoracic/abdominal/pelvic) - percutaneous needle procedure in non-compressible sites, organ - prostatic surgery - surgery sites/minor bleeding/significant morbidity CNS Intraocular - major arthroplasty Discontinuation of warfarin not necessary/ low risk of bleeding - percutaneous needle procedure in compressible sites - many skin procedure - routine dental procedure - endoscopy without biopsy
  14. 14. Risk of thrombosis and need for periprocedural bridging therapy • • • • • • • • • • • • • • • Risk of thrombosis from pre-existing condition -lower risk newer model mechanical aortic valve/ tissue valve AF DVT/PE >3 months hypercoagulable state (no recent/recurrent/life threatening) - higher risk mechanical mitral valve/ old model aortic prosthesis AF + H/O stroke/TIA, > 2 risk factors for cardio embolic events DVT/PE < 3 months DVT/PE in active cancer Hypercoagulable state (recent/recurrent/life threatening) from the procedure - surgeon/ Anesthesiologist
  15. 15. Management based on risk of thrombosis • Low risk • - discontinue warfarin 5 days prior to surgery (-6) • - INR day before procedure (1.5) • - restart warfarin at pre-op dose (hemostasis/ epidural catheter) • - recheck INR – one week • High risk • - discontinue warfarin at least 5 days prior to surgery (-6/-7) • - start LMWH on day -3 • - last dose of LMWH <24hrs • - INR day before procedure (1.5) • - post-op LMWH (12-24hrs) • - restart warfarin at pre-op dose (hemostasis/ epidural catheter) • - continue LMWH until INR therapeutic range – 2 days
  16. 16. Timing of procedure • • • • • • • • • • • • • • • Surgery should be elective if possible If fixed duration anticoagulation – consider delaying invasive procedure Urgent or emergency surgery/procedure - <24 hours discontinue warfarin IV vit K within 6 hours – virally inactivated plasma-derived concentrate check INR before procedure – if not corrected – repeat - 24-96 hours discontinue warfarin IV/PO vit K check INR 24 hours – if not corrected – IV vit K – INR in 12 hours if not corrected – consider – DIC/liver disease check INR prior to surgery
  17. 17. Timing of procedure – contd. • Elective surgery with planned anticoagulant reversal • 5-6 days warfarin free • consider LMWH bridging therapy • check INR one day prior to/on day of surgery
  18. 18. Type of anesthesia • • • • • • • • • • • • LA/GA safe to a patient on warfarin Neuraxial blocks should not be performed - epidural - spinal - retrobulbar If central venous access is needed, a compressible site is preferred In patient with epidural catheters - prophylactic LMWH - not therapeutic LMWH - catheter should not be removed <12 hrs after LMWH dose - no warfarin until epidural catheter is removed - do not give LMWH until after 2 hours of catheter removal
  19. 19. intervention Timing of surgery elective Urgent >24hrs Urgent 24hrs 6- Urgent < 6 hrs Discontinue warfarin 5days prior surgery (-6) immediately immediately immediately LMWH +/- thrombotic risk +/- thrombotic risk NO NO Vitamin K NO PO/IV IV IV Octaplex NO NO NO Preferred Frozen plasma NO NO NO If octaplex not available Recheck INR 24hrs prior surgery 12hrs > vit K 12 hrs > vit K After FP/Octaplex INR >1.5 Postpone if necessary Repeat vit K Repeat vit K, Octaplex/FP if surgery < 6hrs Repeat vit K, Octaplex/FP if surgery < 6hrs
  20. 20. Risk of thrombosis Low risk High risk Pre operative Proceed to surgery <1.5 Elective- LMWH on day -3 Discontinue 24hrs postoperative Restart warfarin at pre-op dose/ hemostasis ensured / epidural catheter removed LMWH 12-24hrs/ hemostasis ensured/ >2hrs of epidural catheter removal Stop LMWH / INR therapeutic range 2 consecutive days
  21. 21. “The darkest places in hell are reserved for those, who maintain their neutrality in times of moral crisis.” -Dante Thank You

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