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How To Stop Warfarin For Surgery: Low Thromboembolic Risk

This document provides guidance on how to stop warfarin medication before surgery based on the patient's thromboembolic risk level. For low risk patients, warfarin should be stopped 5 days before surgery and restarted once oral fluids are tolerated after surgery. For high risk patients, warfarin should be stopped 4 days before surgery and replaced with low molecular weight heparin until 12-18 hours before surgery, then restarted 6 hours after surgery once haemostasis is achieved, along with restarting warfarin. The risks of thromboembolism from withdrawing anticoagulation must be balanced against the risks of perioperative bleeding from continued anticoagulation. Consultation with haematologists is recommended for

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Mahmoud Selim
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81 views3 pages

How To Stop Warfarin For Surgery: Low Thromboembolic Risk

This document provides guidance on how to stop warfarin medication before surgery based on the patient's thromboembolic risk level. For low risk patients, warfarin should be stopped 5 days before surgery and restarted once oral fluids are tolerated after surgery. For high risk patients, warfarin should be stopped 4 days before surgery and replaced with low molecular weight heparin until 12-18 hours before surgery, then restarted 6 hours after surgery once haemostasis is achieved, along with restarting warfarin. The risks of thromboembolism from withdrawing anticoagulation must be balanced against the risks of perioperative bleeding from continued anticoagulation. Consultation with haematologists is recommended for

Uploaded by

Mahmoud Selim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

How to stop warfarin for surgery

Index: Anticoagulation
Original article by: Michael Tam
One would think that there would be guidelines on how, when or if warfarin should be ceased
before surgery but the reality is that this is often not the case. I remember working as a
surgical resident in the pre-operative clinic and having to make this decision on the fly. I can
only hope that the anaesthetic registrar who conducted the (parallel) anaesthetic clinic knew
what he or she was doing.
In a nutshell:
Most patients are on warfarin for a good reason and its cessation may lead to a thromboembolic
event. I do not believe that the risk has actually been quantified, though a useful indicator is to
look at the risk of ischaemic stroke in patients on long term aspirin after its cessation. There is
over a 3-fold increase in risk (1), i.e., substantially higher than the baseline risk for someone
who had never taken aspirin in the first place.
Nevertheless, this has to be balanced against the increased risk of a substantial peri-operative
bleed from anticoagulation. I find the following algorithm (2) instructive (adapted from Sridhar
R., Grigg A.):
Low thromboembolic risk:
stop warfarin 5 days pre-op;
restart warfarin post-op as soon as oral fluids are tolerated.
High thromboembolic risk:
stop warfarin 4 days pre-op and start low molecular weight heparin
(LMWH) at therapeutic dose;
stop the LMWH 12-18 pre-op;
restart LMWH 6 hours post-op (assuming haemostasis achieved);
restart warfarin when oral fluids are tolerated;
stop LMWH when INR = 2.0.
See below for details
Risk of thromboembolism if anticoagulation is withdrawn
Low High
Atrial fibrillation
and/or
cardiomyopathy
Without stroke or systemic
embolisation in the last 12
months
With stroke or systemic
embolisation within the
last 12 months
Biological heart Except during first three During first three
Page 1of 3


Tips
Where in doubt, especially in someone with a complex medical history or an unusual
clotting disorder, ask for help from the haematologists.
valves months months
Prosthesis Vascular grafts
Cardiac mechanical
valves
Venous
thrombosis
Not within the last three
months and without a
confirmed hypercoagulable
state
Within the last three
months, or recurrent
venous thrombosis
Systemic
arterial emboli
Non-recurrent Recurrent
Note: two low-risk factors = high risk
Recommendations for perioperative anticoagulation of patients
undergoing major elective surgery
Day Low-risk patients High-risk patients
-5 Cease warfarin
-4 No anticoagulation Cease warfarin:
Measure INR
Start full dose unfractionated
heparin (UFH) infusion as
inpatient OR LMWH as
outpatient.
Continue daily until day -1.
-1
Stop LMWH a minimum of 12 hours
and UFH six hours before surgery.
+1 Start warfarin as soon as oral
fluids tolerated using the
preoperative maintenance
dose.
Once haemostasis secured, and
generally after at least six hours
post surgery:
recommence LMWH (preferred)
or UFH
start warfarin as soon as oral
fluids tolerated using the
preoperative maintenance dose
Page 2of 3
At the end of the day, there is very little that you can do for thromboembolism while
bleeding is often salvageable. I would err towards bleeding (or where it is particularly
problematic, postponing surgery).
It is the surgeon who cuts the patient so the above algorithm is only a guide. Many
surgeons are much more anxious about operating on an anticoagulated patient.
Dont forget that elective operations are elective (i.e., optional and possibly
unnecessary). Someone who comes in for a total knee replacement and then suffers a
massive disabling stroke is an absolute disaster. Be especially careful with the elective
patients.

Reference articles
(1) Maulaz AB., Bezerra DC., Michel P. Bogousslavsky J. Effect of discontinuing aspirin therapy
on the risk of brain ischemic stroke. Archives of Neurology 62(8):1217-20, 2005 Aug. [Link]
(2) Sridhar R., Grigg A. The perioperative management of anticoagulation. Aust Prescr
2000;23:13-6. [download PDF :: 161 Kb]
Please read the disclaimer
Page 3of 3

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