| Low |
All patients |
- Last dose of warfarin on day -6 pre procedure
- Hold warfarin day -5 through day -1
- Consider vitamin K 2.5mg PO on day -1 pre-procedure if INR > 1.5
- Resume warfarin 12-24 hours post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-op assessment of bleeding risk)
|
| High or Moderate |
CrCl>50 |
- Last dose of warfarin on day -6 pre procedure
- Hold warfarin day -5 through day -1
- Start LMWH on day -3 (or when INR < lower limit of range)
- Consider vitamin K 2.5mg PO on day -1 pre-procedure if INR > 1.5
- Initiate UFH SQ/IV or LMWH when INR falls below lower limit of therapeutic range
- Last dose LMWH 24 hours pre-procedure (on day -1, give ½ dose LMWH if pt is receiving once-daily LMWH
- Resume warfarin 12-24 hrs post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-procedure assessment of bleeding risk)
- Resume LMWH 24 hrs post-procedure (or 48-72hrs for major surgery or high bleeding risk procedure) and continue until INR > lower limit of therapeutic range
|
| CrCl 30-50 |
- Last dose of warfarin on day -6 pre procedure
- Hold warfarin day -5 through day -1
- Start LMWH on day -3 (or when INR < lower limit of range)
- Consider vitamin K 2.5mg PO on day -1 pre-procedure if INR > 1.5
- Initiate UFH SQ/IV or LMWH when INR falls below lower limit of therapeutic range
- Last dose LMWH 36 hours pre-procedure (on day -2, give full dose LMWH if pt is receiving once-daily LMWH)
- Resume warfarin 12-24 hrs post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-procedure assessment of bleeding risk)
- Resume LMWH 24 hrs post-procedure (or 48-72hrs for major surgery or high bleeding risk procedure) and continue until INR > lower limit of therapeutic range
|
| CrCl<30 |
- Last dose of warfarin on day -6 pre procedure
- Hold warfarin day -5 through day -1
- Consider vitamin K 2.5mg po or 1mg IV on day -1 pre-procedure if INR > 1.5
- Admit on day –1 pre-procedure and begin IV UFH (70 U/kg bolus, 15 U/kg/hr infusion and adjust per inpatient protocol)
- Stop IV UFH 6 hours pre-procedure
- Resume warfarin 12-24 hours post-procedure at 1 to 1.5 times usual maintenance dose (decision based on post-op assessment of bleeding risk)
- Resume UFH 24hrs post-procedure (or 48-72hrs for major surgery or high bleeding risk procedure) and continue until INR > lower limit of therapeutic range
|
