Peri-Procedure Management of Anticoagulants Page 1 of 25
Peri-Procedure Management of Anticoagulants
Page 1 of 30
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
TABLE OF CONTENTS
Management According to Procedure Type..¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..¡¡..¡¡.¡..¡¡¡. Page 2
APPENDIX A: Procedure Bleeding Risk¡¡¡¡¡¡¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡..Pages 3-8
APPENDIX B: Reversal of Anticoagulants.¡..¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.........Pages 9-10
APPENDIX C: Management of Anticoagulant for Regional Anesthesia (neuraxial and deep peripheral nerve
procedures, including lumbar puncture).¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡.¡¡.¡..¡¡¡¡¡...Pages 11-12
APPENDIX D: Procedure Bleeding Risk and Management of Anticoagulants for Interventional Spine and Pain
Procedures...¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.¡¡¡.¡.........Pages 13-15
APPENDIX E: Procedure Bleeding Risk and Management of Anticoagulants for Neurosurgery Procedures¡¡¡¡..Pages 16-19
APPENDIX F: Parenteral Anticoagulant Management¡¡¡¡...¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡Pages 20-22
APPENDIX G: Warfarin Management¡......¡¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡¡¡¡¡.¡¡¡¡¡¡¡¡¡¡. Page 23
APPENDIX H: Direct Oral Anticoagulants (DOACs) Management.¡¡¡¡¡¡¡¡.¡¡¡¡¡¡.¡¡¡¡¡¡... Pages 24-25
APPENDIX I: Thromboembolic Risks..¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.¡¡¡¡¡¡¡¡Page 26
APPENDIX J: Child-Pugh Scoring System¡¡¡¡¡¡¡¡¡¡¡¡¡...¡¡¡¡¡¡¡¡...¡¡¡¡¡¡¡¡¡. Page 27
Suggested Readings..¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡ Pages 28-29
Development Credits...¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡¡.Page 30
Copyright 2022 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V7
Approved by the Executive Committee of the Medical Staff on 10/18/2022
Page 2 of 30
Peri-Procedure Management of Anticoagulants
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
PRESENTATION
(Inpatient or Outpatient)
Patient on anticoagulant
scheduled for procedure1
(The primary care team will
determine whether the
procedure can be done safely
while the patient is on an
anticoagulant after discussion
with the patient regarding the
overall risk of bleeding)
EVALUATION
Regional anesthesia
(neuraxial and peripheral
nerve procedures including
lumbar puncture)
or
Interventional spine and
pain procedures
or
Neurosurgery procedures
Other
procedures
Yes
Low
bleeding risk
procedure4?
No
MANAGEMENT PRE- AND POST-PROCEDURE
¡ñ If
urgent or emergent procedure, consider anticoagulant reversal if indicated (see Appendix B)
2,3
¡ñ If possible, delay elective procedures for 1 month after acute VTE or ischemic stroke
¡ñ In patients with new onset atrial fibrillation/atrial flutter who have been on anticoagulation for
< 1 month, recommend TEE to rule out cardiac thrombus prior to holding anticoagulant therapy
¡ñ See Appendix C for management of anticoagulants for regional anesthesia (neuraxial and
peripheral nerve procedures including lumbar puncture)
¡ñ See Appendix D to determine bleeding risk and for management of anticoagulants based on
bleeding risk for interventional spine and pain procedures
¡ñ See Appendix E to determine bleeding risk and for management of anticoagulants based on
bleeding risk for neurosurgery procedures
Continue current
anticoagulant
Urgent/
emergent
procedure?
¡ñ Consider
Yes
1
possible, delay elective
procedures for 1 month after
acute VTE or ischemic stroke2,3
¡ñ In patients with new onset
atrial fibrillation/atrial flutter
who have been on
anticoagulation for < 1 month,
recommend TEE to rule out
cardiac thrombus prior to
holding anticoagulant therapy
For patients on antiplatelet therapy, see Peri-Procedure Management of Antiplatelet Therapy algorithm
For patients with recent ischemic stroke, consult Neurology for further recommendations as indicated
3
Consider removable inferior vena cava (IVC) filter for patients with recent (within 1 month) proximal
lower extremity DVT or PE if procedure cannot be delayed and anticoagulation is expected to be on
hold for > 5 days. Benign Hematology consultation recommended.
4
See Appendix A for Procedural Bleeding Risks based on type of procedure
5
See Appendix I for Thromboembolic Risks
6
If patient is on parenteral anticoagulant, see Appendix F; if on warfarin, see Appendix G; if on DOACs, see Appendix H
2
Copyright 2022 The University of Texas MD Anderson Cancer Center
For restart recommendations, refer
to management based on anticoagulant:
¡ñ Parenteral agents, see Appendix F
¡ñ Warfarin, see Appendix G
¡ñ DOACs, see Appendix H
anticoagulant6
¡ñ Do NOT bridge if patient is on warfarin
¡ñ Do NOT bridge if patient is on DOAC
¡ñ Interrupt
¡ñ If
No
DOACs = direct oral anticoagulants
TEE = transesophageal echocardiogram
VTE = venous thromboembolism
anticoagulant reversal if indicated
(see Appendix B)
¡ñ In patients with new onset atrial fibrillation/atrial flutter
who have been on anticoagulation for < 1 month,
consider TEE to rule out cardiac thrombus prior to
holding anticoagulant therapy
Patient
with low
thromboembolic
risk5?
Yes
anticoagulant6
¡ñ Bridge if patient is on warfarin (see
Appendix G)
¡ñ For moderate risk bleeding procedures,
do NOT bridge if patient on DOAC
¡ñ For high risk bleeding procedures,
bridge if patient on DOAC (see
Appendix H for bridging considerations)
¡ñ Interrupt
No
Department of Clinical Effectiveness V7
Approved by the Executive Committee of the Medical Staff on 10/18/2022
Page 3 of 30
Peri-Procedure Management of Anticoagulants
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
APPENDIX A: Procedure Bleeding Risk
Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.
High Bleeding Risk
Moderate Bleeding Risk
Low Bleeding Risk
General Procedures
¡ñ Regional
anesthesia (neuraxial and deep peripheral nerve
procedures) including lumbar puncture (see Appendix C)
Bone marrow aspiration and biopsy
¡ñ Venous port placement
¡ñ
¡ñ
Ommaya reservoir puncture
Breast Surgical and Breast Radiology Procedures
¡ñ All
OR Breast Surgical procedures
¡ñ Vacuum
assisted breast biopsies (MRI/stereotactic)
¡ñ Core
biopsy of breast and/or axillary level 1 nodal basin
needle aspiration of breast, axillary nodal basins, internal
mammary, and/or supraclavicular lymph nodes
¡ñ Image guided pre-operative localization of the breast and
axillary level 1 nodal basin
¡ñ Breast punch biopsy in clinic
¡ñ Fine
Cardiology Procedures
¡ñ Coronary
¡ñ
¡ñ
¡ñ Endomyocardial
intervention
biopsy
¡ñ Implantable cardioverter-defibrillator/pacemaker lead
extraction
¡ñ Left atrial appendage occlusion device
¡ñ Pericardiocentesis
¡ñ
Diagnostic coronary angiography via femoral access
Electrophysiology testing and/or ablation
¡ñ Pacemaker or defibrillator placement
¡ñ Right heart catheterization
¡ñ Supraventricular tachycardia ablation
¡ñ Transvenous atrial fibrillation ablation
¡ñ
Arterioventricular node ablation
Coronary artery angiography (radial approach)
¡ñ Internal cardiac defibrillator implantation battery change
¡ñ Permanent pacemaker implantation battery change
Dental Procedures1
Alevolar surgery (bone removal)
(root removal)
¡ñ Complex dental procedure/multiple tooth extraction
¡ñ Reconstructive dental procedures
Endodontic (root canal) procedures
Peridontal surgery, abscess incision
¡ñ Up to 2 tooth extractions
¡ñ
¡ñ
¡ñ
¡ñ Apicoectomy
¡ñ
¡ñ
Dental hygiene
Minor dental procedures
Dermatologic Procedures
N/A
1
For moderate risk of bleeding dental procedures in patients on vitamin K antagonists (VKA),
either continue VKA in combination with a pro-hemostatic mouthwash or hold VKA 2-3 days prior to procedure
Copyright 2022 The University of Texas MD Anderson Cancer Center
N/A
Dermatologic procedures
¡ñ Mohs Center procedures
¡ñ
Continued on next page
Department of Clinical Effectiveness V7
Approved by the Executive Committee of the Medical Staff on 10/18/2022
Page 4 of 30
Peri-Procedure Management of Anticoagulants
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
APPENDIX A: Procedure Bleeding Risk - continued
Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.
High Bleeding Risk
Moderate Bleeding Risk
Low Bleeding Risk
Gastroenterology Procedures
Biliary or pancreatic sphincterotomy and/or dilation
¡ñ Cystogastrostomy
¡ñ Endoscopic hemostasis
¡ñ Endoscopic submucosal dissection (ESD), endoscopic
mucosal resection (EMR) or other polypectomy
¡ñ Endoscopic ultrasound with fine needle aspiration
¡ñ Full thickness resection
¡ñ Percutaneous endoscopic gastrostomy (PEG) placement
¡ñ Pneumatic or bougie dilation
¡ñ Therapeutic balloon-assisted enteroscopy
¡ñ Treatment of varices
¡ñ Tumor ablation by any technique
¡ñ
Barrett¡¯s esophagus ablation
¡ñ Colonoscopy with biopsy
¡ñ Diagnostic balloon-assisted enteroscopy
¡ñ Endoscopic retrograde cholangiopancreatography (ERCP)
with stent and/or biopsy
¡ñ Esophageal or enteral stent
¡ñ Gastroscopy with biopsy
¡ñ Sigmoidoscopy with biopsy
¡ñ
Capsule endoscopy
¡ñ Colonoscopy without biopsy
¡ñ Diagnostic esophagogastroduodenoscopy (EGD)
¡ñ Endoscopic retrograde cholangiopancreatography (ERCP)
diagnostic
¡ñ Endoscopic ultrasound without fine needle aspiration
¡ñ Push enteroscopy without biopsy
¡ñ Sigmoidoscopy without biopsy
¡ñ
Gynecology Oncology Procedures
¡ñ
All other Gynecology Oncology procedures
Cold knife conization (CKC)/loop electrosurgical excision
procedure (LEEP)
¡ñ Superficial wide local excisions
¡ñ
Colposcopy
¡ñ Dilatation and curettage
¡ñ Endometrial biopsy
¡ñ Exam under anesthesia
¡ñ Hysteroscopy
¡ñ Insertion/Removal of intrauterine device
¡ñ Laser ablation of the cervix/vulva/vagina
¡ñ Vulvar/vaginal/cervical biopsies
¡ñ
Head and Neck Surgery Procedures
¡ñ All
other Head and Neck Surgery procedures
N/A
¡ñ
Flexible nasopharyngeal laryngoscopy (when performed
outside of the OR)
Continued on next page
Copyright 2022 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V7
Approved by the Executive Committee of the Medical Staff on 10/18/2022
Page 5 of 30
Peri-Procedure Management of Anticoagulants
Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson¡¯s specific patient population, services and structure,
and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to
determine a patient's care. This algorithm should not be used to treat pregnant women.
APPENDIX A: Procedure Bleeding Risk - continued
Note: For patients who have other risk factors for bleeding (e.g., recent bleeding event, thrombocytopenia) consider utilizing the management recommendations for high risk bleeding procedures.
High Bleeding Risk
Moderate Bleeding Risk
Low Bleeding Risk
Interventional Radiology Procedures
Ablations: solid organs, bone, soft tissues, lung
¡ñ Angiography with arterial intervention (e.g., angioplasty) with
access size > 6 French
¡ñ Aortic stent graft
¡ñ Catheter directed thrombolysis (arterial and venous)
¡ñ Gastrostomy, jejunostomy tube placement
¡ñ Intrathecal chemotherapy
¡ñ Lung interventions: biopsy, fiducial placement, intratumoral
injection, and drainage (parenchymal)
¡ñ Percutaneous embolectomy, thrombectomy
¡ñ Portal vein embolization and stenting
¡ñ Solid organ biopsies, fiducial placement, and intratumoral
injection (e.g., liver, prostate, cervical)
¡ñ Solid organ drainage: nephrostomy, biliary, cholecystostomy
¡ñ Spine procedures: vertebroplasty, kyphoplasty (see Appendix D)
¡ñ Transjugular intrahepatic porto-systemic shunt (TIPS)
¡ñ Venous interventions (intrathoracic, intracranial)
¡ñ
Carotid stent placement
¡ñ Catheter exchange < 6 weeks from initial placement (e.g.,
biliary, nephrostomy, abscess, gastrostomy, jejunostomy)
¡ñ Deep, non-organ biopsy, fiducial placement, and
intratumoral injection
¡ñ Diagnostic angiography, with access size up to 6 French
¡ñ Non-organ drainage (e.g., abdominal or retroperitoneal
abscess)
¡ñ Non-tunneled chest tube placement (pleural space)
¡ñ Thoracentesis
¡ñ Trans-arterial embolotherapy
¡ñ Transjugular liver biopsy
¡ñ Tunneled central venous catheter placement
¡ñ Tunneled drainage catheter placement or removal
¡ñ Venous interventions (peripheral)
¡ñ Venous port placement
¡ñ
Catheter exchange > 6 weeks from initial placement (e.g.,
biliary, nephrostomy, abscess, gastrostomy, jejunostomy)
¡ñ Diagnostic angiography (radial approach)
¡ñ Intraperitoneal catheter placement
¡ñ Inferior vena cava filter placement or retrieval
¡ñ Non-tunneled central line placment or removal
¡ñ Paracentesis
¡ñ Superficial (e.g., lymph nodes, thyroid) or palpable mass
biopsies, fiducial placement, and intratumoral injection
¡ñ Superficial abscess drainage
¡ñ Tunneled central venous catheter removal
¡ñ Venous port removal
¡ñ
Neuro-Oncology Procedures
¡ñ
¡ñ
Paraspinal, Diaphragm Electromyography (EMG)
Lumbar puncture (see Appendix C)
¡ñ
Deep muscle (gastrocnemius, infraspinatus, supraspinatus)
EMG
¡ñ
Superficial muscle EMG
¡ñ
Superficial or palpable mass biopsies
Neuroradiology Procedures
¡ñ
¡ñ
Lumbar puncture (see Appendix C)
Solid organ biopsies
¡ñ
Deep, non-organ biopsy
Continued on next page
Copyright 2022 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V7
Approved by the Executive Committee of the Medical Staff on 10/18/2022
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