Guideline for Peri-Procedural Anticoagulation and Bridging ...
Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin
** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **
Classify Procedural Risk of Bleeding
(See Figure A)
Very Low / Low
Anticoagulation (warfarin) WILL NOT need to be interrupted *
Moderate / High / Very High
Anticoagulation (warfarin) WILL need to be interrupted
Classify Patient Risk of Thromboembolism (TE)
(See Figure B)
Low
Bridging NOT indicated*
Moderate
Bridging MAY be indicated*
High
Special Population (VAD)
Bridging IS indicated
See VAD bridging guideline
Discontinue warfarin 5 days before procedure **
Resume warfarin postprocedure based on
procedural risk of bleeding
(See Figure D)
Discontinue warfarin 5 days before procedure **
Clinical judgement should be used to balance the risk of bleeding and clotting to determine if patient should be bridged
or not.
No Bridge
Bridge
Discontinue warfarin 5 days before procedure **
(See Figure C for PreProcedural Bridging)
Resume warfarin/ LMWH post-procedure based on procedural risk of bleeding
(See Figure D)
* For patients NOT requiring warfarin interruption, INR should be checked prior to procedure to ensure not supratherapeutic. For more complex dental procedures, it may be appropriate to hold 1-2 doses if risk of TE is low.
** It maFyigbuerneeAcessary to hold warfarin longer than 5 days for select patient populations (e.g. elderly, liver dysfunction, low dose
requirements, target INR of 3.0 ? 4.0, supratherapuetic INR)
- At the FdiisgcureretioAn of the MD performing the procedure, it may be appropriate to check an INR the day before procedure to
ensure INR is at baseline. If INR is greater than 1.5, a small dose of Vitamin K may be considered - Even in the scenario that "bridging" is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis
Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin
** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **
Figure A
Procedural Bleeding Risk Classification*
Very Low Risk
Dental hygiene or single extraction Selected dermatologic procedures (skin biopsy, skin cancer removal)
Cataract surgery
Low Risk
Arthroscopy Central venous catheter removal Electrophysiologic Testing GI endoscopy without biopsy (colonoscopy,
cystoscopy, gastroscopy) Joint or soft tissue injections Uncomplicated dental procedures
Minor dermatologic procedures other than above
Non-cataract ophthalmologic procedures
Non-coronary angiography
Radial coronary angiography +/- PCI
Internal defibrillator / pacemaker
insertion
Axillary node dissection
Minor intrathoracic surgery
Dilation / curettage
Minor orthopedic surgery (hand, foot,
GI endoscopy with biopsy (colonoscopy /
shoulder, carpal tunnel repair)
cystoscopy / gastroscopy)
Minor vascular surgery
Moderate Risk Hemorrhoidal surgery Minor intra-abdominal surgery (hernia
(endarterectomy, carotid bypass surgery)
repair, hysterectomy, appendectomy, bowel Sternotomy wire removal
resection, cholecystectomy, polypectomy) Selective invasive procedures (bone
Dental surgery / Complex dental procedures
marrow aspirate / biopsy, lymph node
or multiple tooth extractions
biopsy, thoracentesis, paracentesis,
arthrocentesis)
High Risk
Intestinal anastomosis surgery Major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass) Major urologic surgery (prostatectomy, bladder tumor resection) Major lower limb orthopedic surgery (hip replacement, knee replacement) Major thoracic surgery (lobectomy, pneumonectomy) Selected invasive procedures (renal biopsy, lung biopsy, hepatic biopsy, prostate biopsy,
cervical cone biopsy, pericardiocentesis, colonic polypectomy)
Very High Risk Cardiac surgery (coronary artery bypass, heart valve replacement, heart transplantation) Neurosurgery (intracranial or spinal surgery)
* To estimate the risk of bleeding for a specific procedure not included above consider the following: procedures that are likely to incur a higher risk of bleeding include those in a closed area/cavity as well as highly complex or invasive procedures, those involving a large surface area and procedures expected to result in a large amount of inflammation.
Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin
** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **
Figure B
Indication for Anticoagulation
Bioprosthetic Heart Valve
Patient Thromboembolic Risk Classification
Risk Factors
Low Risk Criteria
Moderate Risk Criteria
High Risk Criteria
> 3 months after placement
Within first 3 months of placement
Mechanical Heart Valve
Atrial Fibrillation CHF HTN DM Age > 75 Prior CVA / TIA
Bileaflet aortic valve AND no risk factors
Medtronic Hall tilting disc valve
Bileaflet aortic valve AND 1 or more risk factors
Prior thromboembolism during interruption of warfarin therapy
Any mitral valve prosthesis Older caged-ball / tilting
disc aortic valve prosthesis CVA / TIA (within 6
months)
Atrial Fibrillation
CHADS2-VASc Score CHF (1 point) HTN (1 point) DM (1 point) Prior CVA / TIA / TE (2
points) Age > 75 (2 point) Age 65 ? 74 (1 point) Vascular disease (1 point) Female (1 point)
CHADS2-VASc score 0 to 4 AND no prior CVA / TIA
CHADS2-VASc score 5 to 6
Consider Bridge if CVA / TIA > 3 months
Prior thromboembolism during interruption of warfarin therapy
CHADS2-VASc score 7 CVA / TIA (within 3
months) Rheumatic valvular heart
disease
Venous Thromboembolism
(VTE)
Non-severe Thrombophilia: Heterozygous factor V
Leiden Prothrombin gene mutation
Severe Thrombophilia: Deficiency of antithrombin Protein C or S deficiency Homozygous factor V
Leiden Antiphospholipid antibody
syndrome Heterozygous factor V
Leiden in addition to Prothrombin gene mutation
Single VTE more than 12 months ago AND no other risk factors
VTE within past 3 to 12 months
Non-severe thrombophilia
Recurrent VTE
Prior thromboembolism during interruption of warfarin therapy
Active cancer Less than 3 months since
VTE Severe thrombophilia
Special Populations
Ventricular Assist Device (VAD)
See VAD Bridging Guideline
Note: Previous literature and current guidelines historically risk-stratified patients using CHADS2, however CHADS2-VASc has since been validated and adopted into clinical practice
Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin
** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **
Figure C
Agent Therapeutic LMWH (Dalteparin &
Enoxaparin), dosed Q 12 Hours Therapeutic LMWH (Dalteparin &
Enoxaparin), dosed Q 24 Hours Prophylactic LMWH (Dalteparin &
Enoxaparin), dosed Q 24 Hours Fondaparinux*
IV Unfractionated Heparin (UFH)
Pre-Procedural: BRIDGING
When to Initiate
When to Discontinue**
Give last dose 24 hours prior to procedure
24 to 48 hours after last dose of warfarin (based on INR)
Give last dose 24 hours prior to procedure
Give last dose 12-24 hours prior to procedure Give last dose 36-48 hours prior to procedure Discontinue 4-6 hours prior to procedure
Note: For dosing recommendations, please refer to the drug specific DAG
* There is limited data to support bridging with Fondaparinux; however, this is the drug of choice for patients with Heparin-Induced Thrombocytopenia ** Time between last dose of parenteral agent and procedure may need to be extended in patients with renal dysfunction or if regional anesthesia is required. Please see the BWH Regional Anesthesia in Anticoagulated Patients guidelines for more information.
Figure D
Agent
Warfarin
LMWH (Dalteparin & Enoxaparin), Fondaparinux, IV UFH
Post Procedural: Resuming Anticoagulation
Procedural Bleeding Risk Classification
When to Resume Anticoagulation*
Very Low / Low
Restart evening of procedure
Moderate** High / Very High
Restart evening of procedure Restart evening of procedure * Resumption may be deferred 1-2 days if concerned about bleeding risk
Very Low / Low Moderate**
High/ Very High***
Restart 12-24 hours after Procedure Patient risk for TE = Moderate * Restart 24-48 hours after procedure Patient Risk for TE = High * Restart 24 hours after procedure Patient risk for TE = Moderate * Do not restart LMWH Patient Risk for TE = High * Restart 48-72 hours after procedure
* Hemostasis should be established prior to resumption of any anticoagulation ** Warfarin resumption after procedures thought to have moderate bleeding risk may be deferred for 1-2 days at the discretion of MD if unexpected perioperative bleeding occurs *** For patients at high / very high risk, it may be appropriate to resume LMWH or IV UFH therapy 24 hours after the procedure
- Even in the scenario that "bridging" is not indicated, post-procedure DVT prophylaxis should still be considered in procedures that require routine prophylaxis
- For Moderate risk TE patients with a Moderate procedural bleeding risk: a prophylactic LMWH dose may be used to bridge post-procedure to reduce the risk of bleeding even if therapeutic dose LMWH is used prior to procedure
- For High risk TE patients with a High procedural bleeding risk other options include: o Post-procedure bridging with prophylactic LMWH until bleeding risk minimized then transition back to therapeutic dose LMWH o Post-procedure bridging with prophylactic LMWH only o Resumption of warfarin alone with no LMWH/IV UFH
- Restart warfarin with 15-20% increase of previous maintenance dose & retest INR within 3-4 days
Guideline for Peri-Procedural Anticoagulation and Bridging for Warfarin
** Please note that this guideline may not be appropriate for all patients and does not replace clinical judgment. Consultation with MD performing procedure may be required **
- Due to lack of evidence for preventing arterial TE, some clinicians wouldn't consider Prophylactic LMWH after surgery unless part of routine VTE prophylaxis References:
1. Doherty, J.U., Gluckman, T.J., Hucker, W.J. et al, 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial fibrillation: a report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69:871?898.
2. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med 2015; 373:823.
3. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012.
4. Olesen JB, Lip GYH, Hansen ML, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: Nationwide cohort study BMJ. 2011.
5. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e326S-e350S. doi:10.1378/chest.11-2298.
Approved by Pharmacy and Therapeutics Committee: 11/2017
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- trauma vte prophylaxis guidelines 2020 vumc
- trauma guidelines stanford medicine
- warfarin management adult inpatient clinical practice
- warfarin a comprehensive review uconn health
- guideline for peri procedural anticoagulation and bridging
- thromboprophylaxis after orthopedic surgery
- warfarin management adult ambulatory clinical practice
- deep venous thrombosis prophylaxis in surgical
Related searches
- guideline for isolation precautions cdc 2019
- cdc guideline for isolation precautions
- fha guideline for future employment
- 2017 aha guideline for hypertension
- cms guideline for telehealth
- poverty guideline for family of 2
- poverty guideline for 2021
- cdc guideline for isolation precautions 2020
- aha guideline for heart failure
- chest guideline for dvt
- anticoagulation warfarin bridging decision t
- 2007 guideline for isolation precaution