Management of Anti-coagulation for Surgery

Guideline

These guidelines are designed to aid individual clinical decisions and not replace them. They are
based on the best available evidence but are largely pragmatic as the evidence is not scientifically
strong. Therefore individual clinical judgement remains important.

In each patient the risk of thrombo-embolism needs to be balanced against the risk of surgical
haemorrhagic complications. If the management is uncertain or high risk, a discussion between the
Anaesthetist, Surgeon and/or Haematologist is recommended.

Warfarin & Aspirin

Low Bleeding Risk

Continue all medication as normal
Check INR 5-7 days before surgery Target INR < 3
Reduce Warfarin dose if INR > 3
Repeat INR on day of surgery
If INR > 3 – decision to proceed, delay surgery or reverse anticoagulant

Medium to High Bleeding Risk with Low Thrombotic Risk

Stop Warfarin 5 days before surgery
Continue Aspirin as normal
Check INR on the day before surgery Target INR < 1.5
Repeat INR on day of surgery if > 1.5
If INR still > 1.5 – decision to proceed, delay surgery or reverse anticoagulant
Restart Warfarin at usual dose in the evening after the operation

Moderate to High Thrombotic Risk & High Bleeding Risk

Stop Warfarin 5 days before surgery and bridge with LMW Heparin
Start Enoxaparin 3 days before surgery
- Venous Indication: Enoxaparin 40mg, Subcut, 12 hourly. Omit on day of surgery
- Cardiac Indication: Enoxaparin 1.5mg/kg, Subcut, Daily. Omit on day of surgery
Prophylactic Enoxaparin (40mg) can be given 6 hours post-op if no bleeding
Restart Warfarin at usual dose in the evening after operation
Restart Enoxaparin (at above doses) next day for 3 days / till INR therapeutic

NB: District Nurses work 8am-5pm so they can’t give Enoxaparin exactly 12 hourly

Clopidogrel & Aspirin

Low Bleeding Risk: Continue drugs as normal
High Bleeding & Low Stent Risk: Stop Clopidogrel for 7 Days. Give Aspirin
High Bleeding & High Stent Risk: Consult Cardiologist and Haematologist

NOTE: Enoxaparin dose must be reduced in patients with impaired renal function

Anti-coagulation Guideline (Management of) for Surgery Page 1 of 3

Document Owner: Head of Department Anaesthetics/CQIT
WCDHB-ANAE/CLIN Version 1, Issued 06/09/13 Master Copy is Electronic
Appendix 1
THROMBOTIC RISK

Risk AF DVT / PE Prosthetic Heart Valve

High CHADS2 Score 5 or 6 DVT / PE within the past 3 months Any Mitral Prosthesis

Stroke / TIA within the past 3
months
Rheumatic Valve Disease
Moderate CHADS2 Score 3 or 4
Low CHADS2 Score 2 or less and no
prior Stroke / TIA
Thrombophilia Caged Ball or Tilting Disc Aortic Valve
(deficiency of Protein C, Protein S or
antithrombin, antiphospholipid antibodies or AF + Prosthetic Valve
multiple abnormalities)
Stroke / TIA within the past 6 months
Single VTE within the past 3-12 months Bi-leaflet Aortic Valve plus one of:-
AF
Recurrent VTE’s - irrespective of time span Prior Stroke / TIA
Hypertension
CHF
Diabetes
Age > 75 years
Single VTE > 12 months ago and no other risk Bi-leaflet Aortic Valve and no other risk factors
factors

CHADS2 Score: 1 Point each for Hypertension, CHF (past or present), Age > 75 years, Diabetes
2 Points for history of Stroke, TIA or VTE

Coronary Stents

High Risk: Bare metal < 3 months, Drug eluting < 1 year
Low Risk: Bare metal > 3 months, Drug eluting > 1 year

Anti-coagulation Guideline (Management of) for Surgery Page 2 of 3

Document Owner: Head of Department Anaesthetics/CQIT
WCDHB-ANAE/CLIN Version 1, Issued 06/09/13 Master Copy is Electronic
Appendix 2

PERI-OPERATIVE BLEEDING RISK

Low Risk
Superficial Skin Surgery
Surgery / Biopsy of Compressible Site
Simple Dental Extraction / Conservation
Cataract Surgery
Endoscopy
Haemorrhoidectomy
Joint Aspiration / Injection

Medium Risk
Endoscopy with Biopsy
Hernia Repair (Open or Laparoscopic)
Hysteroscopy with Endometrial Biopsy
Biopsy of Cervix
Urological procedures
Laparoscopic Cholecystectomy

High Risk
Any Surgery requiring Group & Save or Cross-match
Abdominal / Pelvic Surgery
Joint Replacement
Major ENT /Oral Surgery
Regional Anaesthetic Blocks
Prolonged GA with Intubation
Cardiac Surgery
Neurosurgery

This list is for general guidance and is not exhaustive.

In case of any doubt have a discussion with the Surgeon.

Anti-coagulation Guideline (Management of) for Surgery Page 3 of 3

Document Owner: Head of Department Anaesthetics/CQIT
WCDHB-ANAE/CLIN Version 1, Issued 06/09/13 Master Copy is Electronic