PreOp Anticoagulation Decision Support

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Oral Anticoagulants

What oral anticoagulant does the patient take?Warfarin (Coumadin®, others)

Dabigatran (Pradaxa®)

Rivaroxaban (Xarelto®)

Is the surgery or procedure elective or emergent?

Elective Emergent

Thromboembolism Risk• This risk classification is an initial guide for decision-making

that should be adapted to individual patient circumstances. If you are unsure of your patient’s risk of thromboembolism, continue with decision support here.

• If you already know your patient’s risk of thromboembolism, choose a management plan below:– High Thromboembolic Risk – Moderate Thromboembolic Risk – Low Thromboembolic Risk

Is the Patient having a Low Bleeding Risk Procedure?

Low risk bleeding procedures

• Cutaneous procedures: Mohs, excisions and biopsies

• GI procedures: Diagnostic upper endoscopy, enteroscopy and colonoscopy (including biopsies), endosonography and capsule endoscopy

• Dental extraction• Cataract extraction/IOL

Procedures that are not low risk

• Closure after Mohs procedure

• GI procedures: Screening colonoscopy, polypectomy, sphincterotomy, dilatation, ablation, fine needle biopsies, PEG tube placement, therapeutic balloon-assisted enteroscopy, treatment of varices

NoYes

HIGH RISK:Does patient have any of the following?

1) Any mitral valve prosthesis?2) Caged-ball or tilting disc valve prosthesis? (Types of Mechanical Valves)3) Stroke, TIA, or VTE in last 3 months?4) Stroke or TIA with mechanical valve in last 6 months?5) Severe thrombophilia? (examples)6) Rheumatic valvular heart disease with atrial fibrillation?

Yes No

MODERATE RISK: Does patient have any of the following?

1) Bileaflet aortic valve prosthesis with at least one risk factor? (risk factors)2) Atrial fibrillation? (Chad2 Score)3) VTE within past 3-12 months?4) Recurrent VTE?5) Active cancer (treated within 6 months or palliative)?6) Non-severe thrombophilia? (examples)

Yes No

Patient does not meet criteria for moderate or high risk of thromboembolism.

Recommend no bridging therapy during interruption of warfarin based on patient’s history. Click here for suggested management plan.

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No need to stop warfarin before surgery, but adjust warfarin for INR<3.0 on day of procedure (Plan 1).

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Types of Mechanical ValvesValve Type Valve Name(s)

Bileaflet St. Jude; CarboMedics; ATS Open Pivot; On-X; Conform-X

Tilting Disc (single leaflet) Bjork-Shiley (now discontinued); Medtronic Hall; Omnicarbon; Monostrut

Caged-Ball Starr-Edwards (only one FDA approved)

Bioprosthetic (does not require anticoagulation)

Carpentier-Edwards (porcine); Hancock II and Mosaic (both by Medtronic, porcine); Edwards Prima Plus, Medtronic Freestyle, and Toronto SPV (by St. Jude) are pericardial porcine valves.

Prosthetic Heart Valves. Author: Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center.

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CHADS2 Scoring Tool

Characteristic Points

Symptoms due to CHF 1

Hypertension (treated or untreated) 1

Age > 75 years 1

Diabetes 1

Prior Stroke or TIA 2

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Examples of Severe Thrombophilia

• Protein C Deficiency• Protein S Deficiency• Antithrombin Deficiency• Antiphospholipid Syndrome• Multiple abnormalities

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Risk Factors

• Atrial fibrillation• Prior stroke or TIA• Hypertension• Diabetes• Congestive heart failure• Age > 75

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Examples of Non-severe Thrombophilia

• Heterozygous factor V Leiden mutation• Factor II (prothrombin) mutation

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•

Patient is at HIGH risk for thromboembolism

• Recommend bridging patient with therapeutic enoxaparin if bleeding risk acceptable. Click here for suggested bridging plan.

• Consider use of heparin infusion for patients with a mechanical valve.

Patient is at LOW risk of thromboembolism

Recommend no bridging therapy during interruption of warfarin based on patient’s history. Click here for suggested management plan.

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High Thromboembolism Risk Use therapeutic enoxaparin perioperative bridging. (Plan 4)

Day Anticoagulation Plan

Pre-op Day 5 Stop warfarin (last dose on Pre-op Day 6).

Pre-op Day 3 Start therapeutic enoxaparin bridging (1 mg/kg SC q12h) when INR < goal range.

Pre-op Day 1 Consider checking INR, give vitamin K 2.5 mg orally if INR > 1.5. Last dose of therapeutic enoxaparin (if using) must be > 24 hours prior to surgery.

Day of Surgery Check INR, consider additional vitamin K if INR > 1.5. Stop heparin infusion (if using) 4-6 hours prior to surgery.

Post-op Day 1 May resume warfarin this evening if hemostasis achieved.Standard bleeding risk: Resume therapeutic enoxaparin (1 mg/kg SC q12h) or heparin infusion this AM if hemostasis achieved.High bleeding risk: Consider no bridging or low-dose enoxaparin (40 mg SC daily) this AM if hemostasis achieved.

Post-op Day 2 High bleeding risk: Resume therapeutic enoxaparin (1 mg/kg SC q12h) or heparin infusion 48-72 hours after surgery if hemostasis achieved.

Post-op Day 4+ Discontinue bridging when INR has been > 2 for 48 hours.

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Moderate Thromboembolism Risk Use low dose enoxaparin perioperative bridging. (Plan3)

Day Anticoagulation Plan

Pre-op Day 5 Stop warfarin (last dose on Pre-op Day 6).

Pre-op Day 3 Start low-dose enoxaparin (40mg SC daily)

Pre-op Day 1 Consider checking INR, give vitamin K 2.5 mg orally if INR > 1.5. Last dose of any enoxaparin must be > 24 hours prior to surgery.

Day of Surgery Check INR, consider additional vitamin K if INR > 1.5. Assess hemostasis postoperatively.

Post-op Day 1 Resume warfarin this evening if hemostasis achieved.Standard bleeding risk: Resume low-dose enoxaparin (40mg SC daily) or heparin infusion 24 hours after surgery if hemostasis achieved.High bleeding risk: Consider no bridging or low-dose enoxaparin (40 mg SC daily) 24 hours after surgery if hemostasis achieved.

Post-op Day 2 High bleeding risk: Continue (or begin) low-dose enoxaparin (if started post-op day 1) or heparin infusion 48-72 hours after surgery if hemostasis achieved.

Post-op Day 4+ Discontinue bridging when INR has been >2 for 48 hours.

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Emergency SurgeryWhen rapid reversal is required for any INR:1) Discontinue warfarin temporarily2) Administer vitamin K1 2-5mg PO or by slow IV infusion**

3) Supplement with fresh frozen plasma (at least 15ml/kg)4) Recheck INR and administer additional vitamin K1 in 4-8

hrs, if necessary** Intravenous vitamin K should be diluted in 50mL Dextrose 5% and

administered over 20-60 minutes to decrease risk of anaphylaxis. RN should be present during and for 15 minutes after administration to observe for infusion reactions.

ExitReturn to Anticoagulation Bridging Decision Support

High Bleeding Risk Examples• Urologic surgery and procedures consisting of TURP, bladder

resection, or tumor ablation; nephrectomy; or kidney biopsy• Pacemaker or implantable cardioverter-defibrillator device

implantation• Colonic polyp resection, typically of large (1-2 cm long) sessile

polyps• Surgery and procedures in highly vascular organs (kidney, liver,

spleen)• Bowel resection• Major surgery with extensive tissue injury (cancer surgery, joint

arthroplasty, reconstructive plastic surgery)• Cardiac, intracranial, or spinal surgeryReturn to High Thromboembolism Risk Perioperative Bridging

Return to Moderate Thromboembolism Risk Perioperative Bridging

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Dabigatran “Bridging” (Plan 5)• Emergent Surgery:

– Stop dabigatran. If appropriate, consider delaying surgery until aPTT is normal or appropriate amount of time has passed for drug to have cleared (see table below). INR is not a reliable indicator.

– There is no reversal agent for dabigatran. Transfuse FFP, PRBC and platelets as indicated. Consider use of recombinant factor VIIa or hemodialysis. PCC is not available at St. Mary’s Hospital.

– Consider Hematology Consult.• Elective Surgery:

*dabigatran is contraindicated when CrCl ≤ 30 mL/min

Click for a description of High bleeding risk:

Restart dabigatran post-operatively when hemostasis achieved and wound is stable. Bridging anticoagulation is not necessary due to rapid onset of dabigatran, but use of an alternate route anticoagulant (e.g. LMWH) may be appropriate if the patient cannot take medications by mouth.

CreatinineClearance (mL/min)

Dabigatran Half-life (hours)

Last dose of dabigatran prior to surgery

Standard Bleeding Risk High Bleeding Risk

> 80 13 (11-22) 24 hours 2-4 days

> 50 to ≤ 80 15 (12-34) 24 hours 2-4 days

> 30 to ≤ 50 18 (13-23) At least 2 days (48 hours) 4 days

≤ 30* 27 (22-35) 2-5 days > 5 days

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Rivaroxaban “Bridging” (Plan 6)• Emergent Surgery:

– Stop rivaroxaban. If appropriate, consider delaying surgery until PT (not INR) is normal or appropriate amount of time has passed for drug to have cleared (see below).

– There is no reversal agent for rivaroxaban. Transfuse FFP, PRBC and platelets as indicated. Consider use of recombinant factor VIIa. Rivaroxaban is not dialyzable. PCC is not available at St. Mary’s Hospital.

– Consider Hematology consult.

• Elective Surgery: Hold rivaroxaban for 1-2 days prior to surgery based on elimination half-life (5-9 hours in healthy adults, 11-13 hours in elderly adults).

Restart rivaroxaban post-operatively when hemostasis achieved, at least 6-10 hours. Bridging anticoagulation is not necessary due to rapid onset or rivaroxaban, but use of an alternate route anticoagulant (e.g. LMWH) may be appropriate if the patient cannot take medications by mouth.

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ReferencesReturn to Anticoagulation Bridging Decision Support

• Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, 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:e326S-e350S.

• Douketis JD. Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood. 2011;117(19):5044-5049.

• Garcia DA. Update in bridging anticoagulation. J Thromb Thrombolysis. 2011;31(3):259-264.

• Lexi-comp OnlineTM , Lexi-Drugs OnlineTM , Hudson, Ohio: Lexi-Comp, Inc.; September 20, 2011.

• Guidelines for testing and perioperative management of dabigatran. New Zealand Government PHARMAC.

• DeLoughery TG. Practical aspects of the oral new anticoagulants. Am J Hematol. 2011;86:586-590.

Updated Feb 15, 2013Katherine Rotzenberg, PharmD; Roy Kim, MD; Dave Pauly, RPh

Patient is at MODERATE risk of thromboembolism

For patients with moderate risk bridging is not routinely recommended.

– If not bridging then use this plan – If due to unique patient preferences bridging is to

be done then use this plan

Low to Moderate Thromboembolism Risk Adjust warfarin for INR < 1.5 but no

pre or postoperative bridging. (Plan 2)

Day Anticoagulation Plan

Pre-op day 5 Stop warfarin (last dose on Pre-op Day 6).

Pre-op day 1 Consider checking INR, give vitamin K 2.5 mg orally if INR > 1.5.

Day of Surgery Check INR, consider additional vitamin K if INR > 1.5. May resume warfarin the evening of surgery if hemostasis achieved.

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Dabigatran “Bridging” (Plan 5)• Emergent Surgery:

– Stop dabigatran. If appropriate, consider delaying surgery until aPTT is normal or appropriate amount of time has passed for drug to have cleared (see table below). INR is not a reliable indicator.

– There is no reversal agent for dabigatran. Transfuse FFP, PRBC and platelets as indicated. Consider use of recombinant factor VIIa or hemodialysis. PCC is not available at St. Mary’s Hospital.

– Consider Hematology Consult.• Elective Surgery:

*dabigatran is contraindicated when CrCl ≤ 30 mL/min

Restart dabigatran post-operatively when hemostasis achieved and wound is stable. Bridging anticoagulation is not necessary due to rapid onset of dabigatran, but use of an alternate route anticoagulant (e.g. LMWH) may be appropriate if the patient cannot take medications by mouth.

CreatinineClearance (mL/min)

Dabigatran Half-life (hours)

Last dose of dabigatran prior to surgery

Standard Bleeding Risk High Bleeding Risk

> 80 13 (11-22) 24 hours 2-4 days

> 50 to ≤ 80 15 (12-34) 24 hours 2-4 days

> 30 to ≤ 50 18 (13-23) At least 2 days (48 hours) 4 days

≤ 30* 27 (22-35) 2-5 days > 5 days

Dabigatran “Bridging” (Plan 5)

• Emergent Surgery: – Stop dabigatran. If appropriate, consider delaying surgery until aPTT is normal or appropriate amount of time has

passed for drug to have cleared (see table below). INR is not a reliable indicator.– There is no reversal agent for dabigatran. Transfuse FFP, PRBC and platelets as indicated. Consider use of recombinant

factor VIIa or hemodialysis. PCC is not available at St. Mary’s Hospital.– Consider Hematology Consult.

• Elective Surgery:

Creatinine Clearance (mL/min) Dabigatran Half-life (hrs) Last dose of dabigatran prior to surgery Standard Bleeding Risk High Bleeding Risk

> 80 13 (11-22) 24 hours 2-4 days > 50 to ≤ 80 15 (12-34) 24 hours 2-4 days > 30 to ≤ 50 18 (13-23) At least 2 days (48 hours) 4 days ≤ 30* 27 (22-35) 2-5 days > 5 days

*dabigatran is contraindicated when CrCl ≤ 30 mL/min

Restart dabigatran post-operatively when hemostasis achieved and wound is stable. Bridging anticoagulation is not necessary due to rapid onset of dabigatran, but use of an alternate route anticoagulant (e.g. LMWH) may be appropriate if the patient cannot take medications by mouth.