Periprocedural anticoagulation and bridging protocol
| Day . | Intervention . |
|---|---|
| Preprocedural intervention | |
| −7 to −10 | Assess for perioperative bridging anticoagulation; classify patients as undergoing high-bleeding risk or low-bleeding risk procedure; check baseline labs (Hgb, platelet count, creatinine, INR) |
| −7 | Stop aspirin (or other antiplatelet drugs) |
| −5 or −6 | Stop warfarin |
| −3 | Start LMWH at therapeutic or intermediate dose* |
| −1 | Last preprocedural dose of LMWH administered no less than 24 h before start of surgery at half the total daily dose; assess INR before the procedure; proceed with surgery if INR < 1.5; if INR > 1.5 and < 1.8, consider low-dose oral vitamin K reversal (1-2.5 mg) |
| Day of procedural intervention | |
| 0 or +1 | Resume maintenance dose of warfarin on evening of or morning after procedure† |
| Postprocedural intervention | |
| +1 | Low-bleeding risk: restart LMWH at previous dose; resume warfarin therapy |
| High-bleeding risk: no LMWH administration; resume warfarin therapy | |
| +2 or +3 | Low-bleeding risk: LMWH administration continued |
| High-bleeding risk: restart LMWH at previous dose | |
| +4 | Low-bleeding risk: INR testing (discontinue LMWH if INR > 1.9) |
| High-bleeding risk: INR testing (discontinue LMWH if INR > 1.9) | |
| +7 to +10 | Low-bleeding risk: INR testing |
| High bleeding risk: INR testing |
| Day . | Intervention . |
|---|---|
| Preprocedural intervention | |
| −7 to −10 | Assess for perioperative bridging anticoagulation; classify patients as undergoing high-bleeding risk or low-bleeding risk procedure; check baseline labs (Hgb, platelet count, creatinine, INR) |
| −7 | Stop aspirin (or other antiplatelet drugs) |
| −5 or −6 | Stop warfarin |
| −3 | Start LMWH at therapeutic or intermediate dose* |
| −1 | Last preprocedural dose of LMWH administered no less than 24 h before start of surgery at half the total daily dose; assess INR before the procedure; proceed with surgery if INR < 1.5; if INR > 1.5 and < 1.8, consider low-dose oral vitamin K reversal (1-2.5 mg) |
| Day of procedural intervention | |
| 0 or +1 | Resume maintenance dose of warfarin on evening of or morning after procedure† |
| Postprocedural intervention | |
| +1 | Low-bleeding risk: restart LMWH at previous dose; resume warfarin therapy |
| High-bleeding risk: no LMWH administration; resume warfarin therapy | |
| +2 or +3 | Low-bleeding risk: LMWH administration continued |
| High-bleeding risk: restart LMWH at previous dose | |
| +4 | Low-bleeding risk: INR testing (discontinue LMWH if INR > 1.9) |
| High-bleeding risk: INR testing (discontinue LMWH if INR > 1.9) | |
| +7 to +10 | Low-bleeding risk: INR testing |
| High bleeding risk: INR testing |
LMWH regimens include enoxaparin 1.5 mg/kg once daily or 1.0 mg/kg twice daily subcutaneously; dalteparin 200 IU/kg once daily or 100 IU/kg twice daily subcutaneously; and tinzaparin 175 IU/kg once daily subcutaneously. Intermediate-dose LMWH (ie, nadroparin 2850-5700 U twice daily subcutaneously; enoxaparin 40 mg twice daily subcutaneously) has been less studied in this setting
Loading doses (ie, 2 times the daily maintenance dose) of warfarin have also been used.