Anticoagulation management (“bridging”) at the

time of elective surgery and invasive procedures

(adult) Trust Ref: B30/2016

Contents

Contents
Glossary, Document changes ………………… ……………………………………………………………………………………………………2
1. Practical guide: how to use the document: ...................................................................................... 3
2. Introduction...................................................................................................................................... 3
3. Scope ................................................................................................................................................ 4
4. Recommendations, Standards and Procedural Statements ............................................................ 4
5. Warfarin: Stopping warfarin: ............................................................................................................ 5
Warfarin bridging with Low Molecular Weight Heparin (LMWH) and patients on long-term LMWH with
adequate renal function (estimated Creatinine Clearance [CrCl] ≥ 30ml/min): .............................. 5
6. Direct Oral Anticoagulants (DOACs): ................................................................................................ 6
7. Low molecular weight heparins (LMWHs):....................................................................................... 6
8. Risk assessment Bleeding risks:......................................................................................................... 7
Table 1: Bleeding risks associated with procedure type ...................................................................................... 8
9. Thrombotic risks: .............................................................................................................................. 8
Table 2: Thrombotic risks by indication for anticoagulation................................................................................ 9
10. Education and Training ..................................................................................................................... 9
11. Monitoring and Audit Criteria .......................................................................................................... 9
12. Legal Liability Guideline Statement .................................................................................................. 9
13. Supporting Documents and Key References .................................................................................. 10
14. Key Words ...................................................................................................................................... 11
15. Appendices ..................................................................................................................................... 12
Appendix 1 - Warfarin: flowchart for choosing bridging template .................................................................... 12
Appendix 2 - DOACs: flowchart for choosing bridging template ....................................................................... 13

Appendix 10 The CHA2DS2VASc score for estimation of stroke risk in the setting of ATRIAL FIBRILLATION .21

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 Glossary:
Term Meaning
AF, atrial fibrillation Irregular heart rhythm leading to an increased risk of
cardioembolic stroke because of clot development in
the left atrium of the heart
Bridging A broad description of peri-operative anticoagulation
management – it may involve replacing the usual
anticoagulation with full or low dose anticoagulation
(or none)
CHA2DS2VASc A risk assessment tool for atrial fibrillation, giving an
annualised stroke risk
CrCl/Creatinine clearance A measure of renal function; relevant here because of
drug elimination and its effects on some of the
anticoagulants
DOAC/Direct oral anticoagulants A class of oral drugs which act directly to inhibit either
factor IIa or Xa
LMWH/Low molecular weight heparin A form of heparin, used as an anticoagulant in the setting
of peri-operative care and bridging
Major bleed Bleeding into a vital organ/critical site; or leading to a
20g/l drop in Hb; or requiring 2units+ of red cell
transfusions
Thrombotic risk Risk of developing a clot; either venous e.g. deep vein
thrombosis or arterial e.g. Ischaemic stroke
VKA/vitamin K antagonist Anticoagulants which act by reducing the levels of clotting
factors II, VII, IX and X (via vitamin K)
Warfarin The most commonly used VKA

Document changes:
• Highlighted the way to make a referral for anticoagulation bridging for specific cases (VTE within
3 months, HIT, high INR targets), or if the operating team still cannot make a plan after reading
this document.
• Highlighting the responsibility of the operating teams to supply prescriptions as clinically
necessary
• Re-organize the sequence of the contents to prioritize the Practical guide. This is to save clinical
teams some time when they use the document on day to day basis.

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 Anticoagulation management (“bridging”) at the
time of elective surgery and invasive
procedures (adult) Trust Ref: B30/2016

1. Practical guide: how to use the document:

You will need the following information (as a minimum):
• Procedure and its bleeding risk, (+date, time, operator where known)
• Patient weight, renal function
• Name of anticoagulant
• Indication for anticoagulant, and medical history to inform assessment of thrombotic risk

For minimal bleeding risk procedures that do not require significant interruption of
anticoagulation, use APPENDIX 9.
For warfarin use APPENDIX 1 for “bridging template” choice. For DOACs use APPENDIX 2.
Follow the algorithm – this will lead to an appendix which is the template plan that should be
used for this patient.
Print and complete this appendix with patient and operation details (use caution not to print the
entire document!)
Ensure a copy goes to 1. The patient 2. The notes and 3. The patient’s GP
*If additional medications are required (e.g. LMWH), the supply required for bridging
up to 14 days’ worth of medication should be supplied by the operating team; and
education on its use is the responsibility of the operating team.
IMPORTANT NOTE re: CANCELLATIONS: In the event that a procedure is postponed or
cancelled, an active decision should be made about anticoagulation (and other medicines), to
ensure safe medicines management during the time from cancellation to the rebooked procedure.
This clearly needs to be individualised but should involve a risk assessment and decision about
whether to continue with “usual” anticoagulant or stop or bridge. IT IS VERY IMPORTANT TO
COMMUNICATE THIS PLAN CLEARLY TO THE PATIENT (AND WIDER MDT AS
APPROPRIATE).
If patient is already on LMWH then use APPENDIX 8.

2. Introduction
This guideline covers the management of adult patients (age 16 years or more) taking
anticoagulant medication who are due to undergo an elective invasive or surgical procedure. It
provides guidance on:
• Which procedures or operations require stoppage of the patient’s usual anticoagulation
• How to estimate the risk of thromboembolic complications associated with stopping
anticoagulation
• How to safely organise and communicate the plans for anticoagulation at this higher risk
time
There remains a limited service within the haemostasis unit for providing high risk peri-
operative management plans. These plans may be requested via the ICE system if this
guideline does not cover the clinical scenario. This can be found under Service Referrals,
Anticoagulation Bridging. Please note that this will only cover cases of VTE within the last 3
months, patients needing high INR targets, or patients with history of Heparin Induced
Thrombocytopenia. If you think that your patient is not falling within these categories and
you still cannot make a perioperative plan after reading this document, please discuss with
the Haematology SpR.
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 3. Scope
The guidelines pertain to patients > 16years old who require elective surgery and invasive
procedures AND who are taking anticoagulant medications. This includes anticoagulants (e.g.
warfarin, DOACs, heparins) but does not cover anti-platelet therapy.

4. Recommendations, Standards and Procedural Statements

• Anticoagulants generally need to be interrupted prior to major surgical procedures to
minimise peri-operative bleeding risk . However, many minor procedures can be safely
performed without interruption of anticoagulation.
• Interruption of anticoagulation increases peri-operative thrombotic risk (arterial, venous
or cardioembolic) and hence an evaluation of both bleeding and thrombotic risk is
needed. Some facts need to be borne in mind:
• Approximately 20% of arterial thromboembolic events are fatal and 40% result in serious
permanent disability. In contrast, only about 3% of major post-operative bleeding events
are fatal, with most making full and uneventful recovery after haemorrhagic
complications [5]
• Approximately 6% of recurrent venous thromboembolic events are fatal and there is a 3
- 30% risk of longer term post-thrombotic complications (e.g. post thrombotic syndrome,
chronic thromboembolic pulmonary hypertension)

Anticoagulant bridging involves substituting a rapid acting, short half-life anticoagulant for the
long acting usual anticoagulant (typically warfarin) and it was developed because of the long
half-life of warfarin. There are a number of different interpretations of bridging, ranging from
the use of unfractionated heparin and very short interruption of therapeutic anticoagulation, to
the use of therapeutic dose LMWH, to prophylactic dose LMWH. These approaches can be
taken for variable time periods pre and post operatively. This guideline aims to provide a
standard approach to risk assessment and bridging management based on available data
regarding thrombotic risks and outcomes of bridging and peri-operative management of
anticoagulation.

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 With the advent of the rapid-acting and short half-life DOACs and the publication of high
quality evidence with bridging outcomes, it is anticipated that “bridging” will be required much
less frequently. The most important aspects are to identify the individuals at highest risk of
bleeding and thrombosis and to improve their safety; and also to communicate the peri-
procedural management plan for an anticoagulant, even if it is a straightforward stop and
restart of the anticoagulant.
This guideline is divided into warfarin/VKA and DOAC sections for the convenience of the
user.

5. Warfarin:
Stopping warfarin:
Based on the known half-life of [the anticoagulant effects of] warfarin (36-42 hours), it will require
at least 5 days for most of the anticoagulant effect to be eliminated after stopping warfarin. A longer
period (at least 6 days) may be required for elderly patients, patients with congestive cardiac failure,
patients on certain medications and patients on a higher intensity anticoagulation regimen (e.g.
target INR range 3.0-4.0).
Patients on acenocoumarol (Sinthrome), (half-life 8-11 hours), require only about 3-4 days
interruption for elimination of anticoagulant effect.
Warfarin bridging with Low Molecular Weight Heparin (LMWH) and patients on long-term
LMWH with adequate renal function (estimated Creatinine Clearance [CrCl] ≥ 30ml/min):
• LMWH should generally be started 36-48 hours (approx. 2 days) after last dose of warfarin. For
the purpose of full bridging, a therapeutic dose is required. Prophylactic doses are used when
the risk of stopping an anticoagulant is low from the cardio-embolic point of view but where there
is a risk of venous thromboembolism (VTE).
• Therapeutic dose Enoxaparin (i.e.1mg/kg BD): twice daily dosing is preferred for bridging.
Administer half dose (1mg/kg OD) on day before procedure and ensure at least 24 hour interval
between last dose and time of procedure. Full anticoagulation may need to be withheld for up to
48-72 hours with high bleed risk procedures; in these circumstances, prophylactic doses may
be administered safely in the interim.
• Prophylactic dose Enoxaparin: some clinical situations do not require bridging with LMWH;
warfarin is simply stopped 5-6 days pre-operatively and recommenced, usually at previous
maintenance dose, and dose- titrated over time to achieve the desired therapeutic INR.
Prophylactic dose LMWH may be restarted from 6 hours post-procedure (provided haemostasis
is secure) and continued from the first post-op day, and administered concurrently with warfarin
until the INR is in the desired therapeutic range before withdrawing LMWH.
• Warfarin bridging for patients with impaired renal function (estimated CrCl < 30 ml/min):Prophylactic
Enoxaparin (see weight base dosing table on UHL Connect) can usually be administered safely
without need for drug (anti-Xa/heparin level) monitoring and without risk of accumulation, however,
where CrCl is <15ml/min monitor heparin assay on day 4 and every 4 days to ensure there is no
accumulation. Aim for peak levels <0.3iu/ml.

• Special categories of patients: The following categories of patients should be referred to the
consultant overseeing the patient to make decisions regarding peri-procedural anticoagulation,
unless a specific local guideline is in place for the scenario in question. A referral to the
Haemostasis & Thrombosis clinic would be reasonable in such cases:.
o pregnant women with mechanical heart valves,
o patients with history of heparin induced thrombocytopenia who require bridging
o bariatric patients (weight > 150 kg) or underweight adults (< 40kg),
o patients with known bleeding disorders or an abnormal bleeding history
o patients with CrCl < 15ml/min (see dosing table)

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 A note on patients with mechanical prosthetic heart valves undergoing high bleeding risk
procedures:
• The overall risk of valve thrombosis and/or cardio-embolisation in non-surgical patients after
suspension of anticoagulation is very low (< 0.2% over a 7 day period) [11]. Mechanical
valves in the mitral position carry the highest thrombosis risk without anticoagulation, whereas
modern prosthetic aortic valves (e.g. On-X) have a lower risk. In the peri-operative setting, a
retrospective analysis of 180 non-cardiac operations in 159 patients with valve prostheses in
whom anticoagulation was withheld for an average total period of 6.6 days, the post-operative
thromboembolic rate was 0% [2]. Consequently, in patients undergoing high bleeding risk
procedures, full therapeutic anticoagulation can be safely be withheld for up to 72 hours.

6. Direct Oral Anticoagulants (DOACs):

This document also provides guidance for the management of peri- procedural
anticoagulation for adult patients taking the direct oral anticoagulants (DOACs) Apixaban,
Dabigatran, Edoxaban and Rivaroxaban, and who require elective surgery or invasive
procedures.
The DOACs have a rapid onset of action (approx. 1-3 hrs to peak concentration) and a
shorter half-life than warfarin. Typically, anticoagulants that require stopping should be
stopped for 3-5 half-lives, depending on procedural bleeding risk. Depending on renal
function, the DOACs have a half-life range of around 9-18 hrs (typically around 12hrs).
The PAUSE study (JAMA 2019) provided good evidence that the information contained within
the summary of product characteristics for the DOACs was a safe approach to invasive
procedures with the DOACs, and alongside other publications, provides the templates for
peri-operative management of DOACs within this guideline.

7. Low molecular weight heparins (LMWHs):

Some patients may be prescribed low molecular weight heparin for their usual anticoagulant
therapy or in anticipation of surgery (e.g. some cancer associated VTE). In this case, bridging
is not required but the dosing of heparin is usually split to twice daily therapeutic dosing in
advance of a procedure. Therapeutic anticoagulation with LMWH may be restarted after 48-
72 hours. Details for this are shown in appendix 8.

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 8. Risk assessment
Bleeding risks:

For patients on oral anticoagulant therapy requiring invasive procedures, the risk of a
thromboembolic event in the peri-operative period when anticoagulation is interrupted must
be balanced against the risk of bleeding when these are continued. If the risk of procedure-
related bleeding whilst continuing oral anticoagulation is thought to be small,
anticoagulation may be continued.
If the risk of procedure-related bleeding is thought to outweigh the risk of thromboembolic
events, anticoagulation should be stopped and bridging anticoagulation considered
depending on the thrombotic risk. If bridging anticoagulation is instituted, this should be
done in a manner whereby both the time without anticoagulation and the bleeding risk are
minimised. The peri- procedural management therefore depends both on individual patient
characteristics and the type of procedure.
For some invasive procedures, such as minor dental (Douketis et al, 2012; Perry et al,
2007), joint injections (Ahmed & Gertner, 2011), ophthalmic such as cataract (Jamula et al,
2009), dermatological (Douketis et al, 2012) and certain endoscopic procedures (Veitch et
al, 2016), anticoagulation may not need to be stopped. Procedures that require
anticoagulation to be stopped will vary in their bleeding risk and, importantly, the
consequences of bleeding will depend on the site of surgery and local anatomy. Although
some have grouped procedures into lower or higher risk (Spyropoulos & Douketis, 2012;
Baron et al, 2013) the operating surgeon, dentist, or interventional radiologist may wish to
assess the risk of bleeding for the individual patient and discuss both this and the plan for
peri-operative anticoagulation with them. The plan must be recorded clearly in the notes,
including a plan for when the patient is discharged.
The risk of bleeding is best assessed by the surgeon or operator. Table 1 lists common
minimal, low and high risk of bleeding procedures as a guide. We recommend assessment of
bleeding risk by operators to help those performing the pre-operative assessment. (Note that
this list is not comprehensive and is intended as guidance only.).
Departments may wish to assign a bleeding risk to their procedures based on local
evidence and experience, and this should perhaps be encouraged. Once assigned, the
templates for anticoagulation management should then be used to help communicate the
plan for an individual patient (see appendices).

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 Table 1: Bleeding risks associated with procedure type
High bleeding risk. (2 day Medium/Low bleeding risk. Very low bleeding risk
risk of major bleed >=2%) (2 day risk of major bleed
<2%)
Major surgery (extensive Arthroscopy Minor skin surgery
tissue injury or duration
>45mins)
Cancer surgery Cutaneous lymph node Cataract surgery
resection
Major orthopaedic surgery Shoulder/foot/hand surgery Most dental procedures (inc
extractions, restorations,
prosthetics, endodontics)
Reconstructive plastic surgery Coronary angiography Pacemaker or defibrillator
implantation
Urology surgery, inc Gatrointestinal/Colonic
transurethral prostate endoscopy +- biopsy
resection, bladder resection,
(excluding polyp removal)
bladder tumour ablation
Gastrointestinal surgery Abdominal hysterectomy
Nephrectomy Laparoscopic cholecystectomy
Renal biopsy Abdominal hernia repair
Percutaneous gastrostomy Haemorrhoid surgery
placement
Endoscopic retrograde Bronchoscopy +-biopsy
cholangiopancreatography
(ERCP)
Cardiac surgery Epidural injection
Spinal surgery
Colonic polyp resection

9. Thrombotic risks:
This guideline recommends stratification of thrombotic risk as Low risk or High risk based on
the indication for anticoagulation (table 2 below). The risk assessment influences decision
making about the need for therapeutic bridging anticoagulants for those taking warfarin/VKA.
The thrombotic risk is less relevant for patients taking DOACs because full therapeutic
bridging would generally not be required because of the pharmacokinetic properties. Low risk
in this context is simply relative to high risk for patients prescribed anticoagulants rather than
indicating absolute thrombotic risk. These risks should also be considered in the wider
context of VTE risk assessment, which is a standard of care for all patients.

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 Table 2: Thrombotic risks by indication for anticoagulation
High thrombotic risk Low thrombotic risk

Mechanical valve replacement: mitral position Mechanical valve replacement: aortic position,
modern bileaflet type WITHOUT additional
cardiovascular risk factors*
Mechanical valve replacement: aortic position,
modern bileaflet type WITH additional
cardiovascular risk factors*
Mechanical valve replacement: aortic position-
valve type uncertain, esp if replaced > 25 years
ago

Arterial thromboembolism, including stroke and

left ventricular thrombus

Non-valvular atrial fibrillation with Non-valvular atrial fibrillation with

CHA2DS2Vasc score ≥ 6 CHA2DS2Vasc score < 6

Venous thromboembolism with target INR > 2.5 Venous thromboembolism with target INR 2.5

Antiphospholipid syndrome with any history of Cerebral/obstetric antiphospholipid

arterial or venous thrombosis syndrome/Positive laboratory results for
antiphospholipid syndrome WITHOUT
thrombosis
*Age > 75 years, Diabetes mellitus, Hypertension, Atrial fibrillation, Congestive cardiac
failure, non-bileaflet mechanical valve (more likely for valves replaced 25 years+ ago)

•N.B. This document provides general guidance only and is not a substitute for clinical
judgment of an individual patient. Complex patients or patients in whom there are specific
concerns regarding thrombosis or bleeding risk may be discussed with a haematologist
when making a preoperative anticoagulation plan.
10. Education and Training
This guideline replaces a previous similar guideline for peri-operative management of
anticoagulation. As such, it will be familiar to those areas who need to manage this clinical
scenario. Communications will be sent out after ratification and publication of the guideline
It is the responsibility of operating teams to familiarise themselves with the policy and adapt
and use according to their particular needs. Additional training and education may be available
on request from the anticoagulation nursing team.

11. Monitoring and Audit Criteria

Key Performance Indicator Method of Assessment Frequency Lead

Evidence of risk assessment audit annual Surgical
pre-op specialty lead
Peri-op plan in notes audit annual Surgical
specialty lead
Peri-op thrombosis rate audit annual Surgical
specialty lead
Peri-op bleeding rate audit annual Surgical
specialty lead

12. Legal Liability Guideline Statement

See section 6.4 of the UHL Policy for Policies for details of the Trust Legal Liability statement
for Guidance documents

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 13. Supporting Documents and Key References
• McKenna R . Abnormal coagulation in the postoperative period contributing to excessive
bleeding Med Clin North Am . 2001 ; 85 ( 5 ): 1277 - 1310 .
• Tinker JH, Tarhan S. Discontinuing anticoagulant therapy in surgical patients with cardiac valve
prostheses. Observations in 180 operations . JAMA . 1978 ; 239 ( 8 ): 738 - 739 .
• Katholi RE , Nolan SP , McGuire LB . The management of anticoagulation during non- cardiac
operations in patients with prosthetic heart valves. A prospective study. Am Heart J . 1978 ; 96
( 2 ): 163 - 165
• Torn M , Rosendaal FR . Oral anticoagulation in surgical procedures: risks and
recommendations . Br J Haematol . 2003 ; 123 ( 4 ): 676 - 682 .
• Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J
Med 1997; 336: 1506
• Douketis DJ et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation.
June 22, 2015DOI: 10.1056/NEJMoa1501035
• Tincani E, Mannucci C, Casolari B, et al. Safety of dalteparin for the prophylaxis of venous
thromboembolism in elderly medical patients with renal insufficiency: a pilot study.
Haematologica 2006; 91:976-979
• Cook D, Douketis J, Meade M, et al. Venous thromboembolism and bleeding in critically ill
patients with severe renal insufficiency receiving dalteparin thromboprophylaxis: prevalence,
incidence and risk factors. Crit Care. 2008; 12(2): R32

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 • Lim W, Dentali F, Eikeelboom JW, and Crowther MA. Meta-analysis: low-molecular- weight
heparin and bleeding in patients with severe renal insufficiency. Ann Intern Med 2006;144:673-
684
• Symes J. Low molecular weight heparins in patients with renal insufficiency. CANNT J
2008;18(2)55-61
• Rabbat CG, Cook DJ, Crowther MA, McDonald E, Clarke F, Meade MO, Lee KA, Cook RJ.
Dalteparin thromboprophylaxis for critically ill medical-surgical patients with renal insufficiency.
J Crit Care. 2005 Dec;20(4):357-63
• Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in
patients with mechanical heart valve prostheses. Circulation 1994;89:635–41
• Douketis DJ et al. Antithrombotic therapy and prevention of thrombosis, 9TH Ed: ACCP
GUIDELINES Chest 2012
• Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative Management of Patients With
Atrial Fibrillation Receiving a Direct Oral Anticoagulant. JAMA Intern Med.
2019;179(11):1469–1478. doi:10.1001/jamainternmed.2019.2431
• Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for
predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based
approach: the euro heart survey on atrial fibrillation. Chest. 2010 Feb;137(2):263-72. doi:
10.1378/chest.09-1584. Epub 2009 Sep 17. PMID: 19762550.
• Ahmed, I. & Gertner, E. (2011) Safety of arthrocentesis in patients on chronic warfarin therapy
with therapeutic INR. Journal of Hospital Medicine
• Perry, D.J., Noakes, T.J. & Helliwell, P.S. (2007) Guidelines for the management of patients
on oral anticoagulants requiring dental surgery. Br Dent J, 203, 389-393.
• Jamula, E., Anderson, J. & Douketis, J.D. (2009) Safety of continuing warfarin therapy during
cataract surgery: a systematic review and meta-analysis. Thrombosis Research, 124, 292-299

14. Key Words

Bridging, anticoagulation, anticoagulant, pre-assessment, peri-operative

This table is used to track the development and approval and dissemination of the document, and any
changes made on revised / reviewed versions
DEVELOPMENT AND APPROVAL RECORD FOR THIS
DOCUMENT
Author / Lead Dr Stella Salta Job Title: Haematology
Officer: consultant
Reviewed by: Dr A Mistri, Dr S Salta, Dr B Myers, Jo Mahoney, Mr A Boddy,
Gynaecology pre- assessment nursing team, Dr J Stewart, Haemostasis
nursing team
Approved by: Date Approved:

REVIEW RECORD
Date Issue Reviewed By Description Of Changes (If Any)
Number
4/6/2024 S. Rudge, S Salta Change Dalteparin to Enoxaparin, INR target in
appendix 1 from 2.5 to range 3.5 - 4.5
18/10/2024 Dr Omar Mukhlif Review and update.

DISTRIBUTION RECORD:
Date Name Dept Received

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15. Appendices

Appendix 1 - Warfarin: flowchart for choosing bridging template

Indication for warfarin

Arterial
thromboembolism, Other, including
including stroke/APLS Atrial fibrillation history of heparin
induced
(non-valvular) thrombocytopenia,
Mechanical heart valve Venous VTE with INR range
thromboembolism with 3.5-4.5 or above,
INR target 2.5 recent thrombosis
<3m

Aortic with any additional Aortic with no additional

BRIDGE Check CHA2DS2-VASc Mitral position risk factors
risk factor (see below)
score
Appendix 4 BRIDGE BRIDGE NO BRIDGING REQUIRED
Appendix 10
Appendix 4 Appendix 4 Appendix 3

Score ≤ 5 Discuss/refer to
NO BRIDGING REQUIRED haemostasis team
Appendix 3 Risk factors:
Any one of: Age > 75 years, Diabetes mellitus,
Hypertension, Atrial fibrillation, congestive cardiac
disease, non-bileaflet or replaced > 25 years ago NO BRIDGING.
Score ≥ 6
Ensure post op
BRIDGE thromboprophylaxis until
Appendix 4 INR in range
Appendix 3

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 Appendix 2 - DOACs: flowchart for choosing bridging template

DOAC (all indications)

Apixaban, Edoxaban, Dabigatran Dabigatran

Rivaroxaban Creatinine clearance Creatinine clearance
All renal function 30-49 ml/min 50+ml/min

Low bleed risk procedure Low bleed risk procedure Low bleed risk procedure
Use Appendix 5 Use Appendix 6 Use Appendix 5

High bleed risk procedure High bleed risk procedure High bleed risk procedure
Use Appendix 6 Use Appendix 7 Use Appendix 6

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 Appendix 3. Peri-op plan for warfarin: no
bridging

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day Warfarin dose Enoxaparin Dose

-6 Last dose of warfarin

(Tested INR in the range 3.0-
4.0 or 2.5-3.5)

Date: No therapeutic bridging.

-5 Last dose of warfarin
(INR range 2.0-3.0) Assess need for
Date:
thromboprophylaxis as per
-4 No warfarin
Date: UHL guidelines.
-3 No warfarin
Date: Tick boxes below if required
-2 No warfarin
Date:
-1 No warfarin
Date:
0 (day of procedure) Restart warfarin at usual 6 hours post Prophylactic
Date: maintenance dose in the Enoxaparin (provided haemostasis
evening is secure)
Tick box if required (mandatory if prior
history of VTE) □

+1 Warfarin at maintenance Prophylactic Enoxaparin □

Date: dose Dose:
+2 Warfarin at maintenance Prophylactic Enoxaparin □
Date: dose Dose:
+3 ( Check INR) Warfarin at maintenance Prophylactic Enoxaparin □
Date: dose Dose:
+4 (Check INR) Dose titrate warfarin until Stop Enoxaparin when INR is in
Date: INR in therapeutic range therapeutic range.
(Check INR)

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 14 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library
 Appendix 4. Peri-op plan for warfarin: bridging required
CrCl >30 ml/min

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day Warfarin dose Enoxaparin Dose

-6 (INR range 3.0-4.0 or 2.5- Last dose of warfarin Nil

3.5, age >75 years, Congestive
cardiac failure)
Date:
-5 (INR range 2.0-3.0) Last dose of warfarin NIL
Date:
-4 No warfarin NIL
Date:
-3 No warfarin 1mg/kg am 1mg/kg pm
Date: Dose: Dose:
-2 No warfarin 1mg/kg am 1mg/kg pm
Date: Dose: Dose:
-1 No warfarin 1mg/kg am Omit evening dose
Date: Dose:
LAST DOSE ADMINISTERED NO LESS THAN
24 HOURS PRE-OPERATIVELY
0 (day of procedure) Restart warfarin at usual Pre: NIL
Date: maintenance dose
Post: Start prophylactic dose
Enoxaparin from 6 hrs post procedure
providing haemostasis secure
+1 Warfarin at maintenance Prophylactic dose Enoxaparin
Date: dose Dose:
+2 Warfarin at maintenance Prophylactic dose Enoxaparin
Date: dose Dose:
+3 Warfarin at maintenance Recommence 1mg/kg BD Enoxaparin
Date: dose Dose:
(Check INR day +3, day Twice daily
+4 or day+5)
Onward management plan: Dose titrate warfarin Stop Enoxaparin when INR is in
until INR in therapeutic therapeutic range
range. Check INR as
indicated by previous
result

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 15 of 21
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NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library
 Appendix 5. Peri-op plan for DOAC: anti-Xa drugs: low bleed risk

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day DOAC Enoxaparin

Insert name of
DOAC here:
……………………..
-2 Last dose of DOAC
Date:
-1 No DOAC
Date:
0 (day of procedure) No DOAC Start prophylactic Enoxaparin 6-12 hrs
Date: post procedure following VTE risk
assessment providing haemostasis is
secure
Tick box if required
Dose:
+1 Start DOAC 24h after Stop Enoxaparin when DOAC starts
Date: procedure Delay DOAC if
ongoing bleeding risk and
reassess every 24h
Onward management plan: Continue DOAC Stop Enoxaparin when DOAC starts

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 16 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
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 Appendix 6. Peri-op plan for DOAC: anti-Xa drug with high bleed risk OR Dabigatran
(see notes on bleed risk and CrCl)

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day DOAC Enoxaparin

Insert name of
DOAC here:

……………………..
-3 Last dose of DOAC No pre-operative Enoxaparin
Date:
-2 No DOAC
Date:
-1 No DOAC
Date:
0 (day of procedure) No DOAC Start prophylactic Enoxaparin 6-12 hrs
Date: post procedure following VTE risk
assessment providing haemostasis is
secure
Tick box if required
Dose:
+1 No DOAC Prophylactic Enoxaparin
Date: Dose:
+2 Start DOAC from 48h post Stop Enoxaparin when DOAC starts
Date: procedure. Delay DOAC if
ongoing bleeding risk and
reassess every 24h
Onward management plan: Continue DOAC

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 17 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library
 Appendix 7. Peri-op plan for Dabigatran: high bleed risk
(with CrCl 30-49ml/min)

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day Dabigatran Enoxaparin

-5 Last dose of Dabigatran No pre-operative Enoxaparin

-4 No dabigatran No Enoxaparin
-3 No Dabigatran No Enoxaparin
Date:
-2 No Dabigatran
Date:
-1 No Dabigatran
Date:
0 (day of procedure) No Dabigatran Start prophylactic Enoxaparin 6-12 hrs
Date: post procedure following VTE risk
assessment providing haemostasis is
secure
Tick box if required
Dose:
+1 No Dabigatran Continue prophylactic Enoxaparin
Date: until bleeding risk reduced and safe to
start
DOAC
+2 Restart Dabigatran from Stop Enoxaparin when DOAC starts
Date: 48 hrs post procedure.
Delay DOAC if ongoing
bleeding risk and
reassess every 24h
Onward management plan: Continue Dabigatran

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 18 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library
 Appendix 8. Peri-op plan for Enoxaparin: pause and restart
CrCl >30 ml/min

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Day Enoxaparin AM Enoxaparin PM

-2 1mg/kg am 1mg/kg pm
Date: Dose: Dose:
-1 1mg/kg am Omit evening dose
Date: Dose:
LAST DOSE ADMINISTERED NO LESS THAN 24 HOURS PRE-
OPERATIVELY
0 (day of procedure) Pre: NIL
Date:
Post: Start prophylactic dose Enoxaparin from 6 hrs
post procedure providing haemostasis secure
+1 Prophylactic dose Enoxaparin OD
Date: Dose
+2 Prophylactic dose Enoxaparin OD
Date: Dose:
+3 Recommence Enoxaparin 1mg/kg am Enoxaparin 1mg/kg pm
Date: Dose: Dose:
Onward management plan: Enoxaparin may continue twice daily OR convert to once daily
OR switch to oral anticoagulant depending on thrombotic
factors

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 19 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library
 Appendix 9. Peri-op plan for minimal bleed risk procedure: no interruption of
anticoagulation

S Number Procedure:

Name Date of procedure:

Date of Birth Operator:

Address Location:

Anticoagulation management plan:

This procedure carries a very low bleeding risk and so you will not need to significantly interrupt
your anticoagulant therapy.

Please do the following (please circle):

Continue all doses

Omit the morning dose then continue as usual

Omit all doses on the day of the procedure then continue as usual

Other: ……………………………………………………………………………

Completed by: Signed Date:

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 Appendix 10 The CHA2DS2VASc score for estimation of stroke risk in the setting of
ATRIAL FIBRILLATION

Tick as required

Congestive heart failure 1

Hypertension 1

Age 65-74 1

Age 75+ 2

Diabetes mellitus 1

Previous stroke/TIA 2

Vascular arterial disease (including coronary, carotid, peripheral) 1

Female 1

Score

Completed by: Signed Date:

Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 21 of 21
Latest version approved by Clinical Policy and Guideline Committee on November 2024 Trust Ref: B30/2016 Next Review: November 2029
NB: Paper copies of this document may not be most recent version. The definitive version is held on InSite in the Policies and Guidelines Library