Chapter 5

Managing anticoagulation during procedures/surgeries

Problems

• Lack of good database.
• Most physicians use their own approaches which vary and is inconsistent. Some of these approaches have not been based on good principle, but rather a guessing or compromised one.

Guidelines.

• Assess the thromboembolic risk of the condition that requires the anticoagulation treatment.
• Assess the bleeding risk of the procedure/surgery that will be performed.
• Possibility of hypercoagulable state induced by the withdrawal of warfarin (rebound phenominon) or the surgical milieu resulting in greater perioperative thromboembolic events than what would be predicted based on the annual thromboembolic rate during nonsurgical settings (Table 9).
• Post major operative venous thromboemboli are more common, while post operative arterial thromboemboli are rare.
• Permanent disability or death is substantially more common after arterial thromboembolism (70-75%) compare to following venous thromboembolism (4-10%). Permanent disability or death after postoperative major bleeding is lower, at about 1-6%.
• Individualization.
• Select the plan in the "Protocol for managing anticoagulation during procedures/surgeries (5 plans)", then follow the detail of that plan in the "Detail of the protocol for managing anticoagulation during procedures/surgeries (5 plans) "
• Using the protocol will make this management more uniform.

  Protocol for managing anticoagulation during procedures/surgeries.

  • 5 plans for different days of inadequate anticoagulation ranging from 0 to 7 days. These plans include (1) Continue warfarin; (2) Hold warfarin, pre and post heparin; (3) Hold warfarin, post heparin; (4) Hold warfarin, pre heparin: (5) Hold warfarin only.Using low molecular weight heparin allows us to use this protocol out of the hospital both pre and post procedures/surgeries, if necessary.
  • Too early post operative full dose heparin is associated with more bleeding complication, while pre operative heparin rarely causes bleeding, if withheld it at appropriate time.
    

  For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery".

Bridging Therapy is the procedure involving temporary use of heparin when the warfarin is withheld.

Thromboembolic Risks

Table 9. Risk of thromboembolism on patients without anticoagulation therapy. (Not during withholding warfarin for procedure/surgery). (Adapted from Kearon C, Hirsh J. Management of Anticoagulation Before and After Elective Surgery. NEJM 1997; 336:1506-1511).

CONDITIONS	RATE* OF THROMBO- EMBOLISM	RATE PER DAY	RISK REDUCTION WITH THERAPY
VENOUS	.
Acute VTE	.
-- Month 0-1	40% / month	1.3	80%
-- Month 1-3	10% / month	0.3	80%
Recurrent VTE	15 % / year	0.04	80%
ARTERIAL	.
Acute arterial embolism	.
-- Month 0-1	15% / month	0.5	66%
NVAF	4.5% (1-20) / year	0.01	66%
NVAF and previous embolism	12% / year	0.03	66%
Mechanical heart valve	8%† / year	0.02	75%

• VTE = Venous thromboembolism.NVAF = Non valvular atrial fibrillation.* = Average
• † = Varies with type, position, and multiple prostheses.

(Rate of thromboembolism may be higher following holding warfarin and during surgical procedures - "rebound phenominon")

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Patients with high risk for thromboembolism.
(1 year risk of arterial embolism > 10%, or 1 month risk of venous thromboembolism > 10 %)

• Known hypercoagulable state: Protein C, protein S and antithrombin III deficiency. Factor V Leiden and prothrombin gene mutation.
• Antiphospholipid antibody syndrome (APS), SLE with cardiolipin antibodies.
• Recurrent arterial or idiopathic venous thromboembolism events.
• Venous or arterial thromboembolism within the preceding 1-3 months.
• Rheumatic atrial fibrillation.
• Acute intracardiac thrombus visualized by echocardiogram.
• Atrial fibrillation plus mechanical heart valve in any position.
• Older mechanical valve model in mitral position.
• Recently placed mechanical valve (<3 months).
• Atrial fibrillation with history of cardioembolism.

Patients with intermediate risk for thromboembolism.
(1 year risk of arterial embolism of 5 to 10%, or 1 month risk of venous thromboembolism of 5 to 10 %)

• Recurrent CVA or TIAs without risk factors for cardiac embolism.
• Atrial fibrillation without history of cardiac embolism but with multiple risks for cardiac embolism (LV ejection <40%, diabetes, hypertension, nonrheumatic valvular heart disease, transmural myocardial infarction within preceding month)
• Venous thromboembolism 3-6 months.

Patients with low risk for thromboembolism.
(1 year risk of arterial embolism < 5%, or 1 month risk of venous thromboembolism < 2%%)

• Venous thromboembolism >6 months.
• Atrial fibrillation without multiple risks for cardiac embolism.
• Newer model prosthetic valve in aortic position >3 months.

Bleeding Risks

1. Low risk.
   • Cutaneous: Local skin surgery, i.e. Mohs micrographic surgery, simple excisions, biopsy and repairs.
   • Oral: Simple dental procedures, i.e. simple tooth extraction, dental hygiene, restorations, endodontics, prosthetics and periodontal therapy. (Some dentists give antifibrinolytic agents such as tranexamic acid or epsilon aminocaproic acid mouthwash to help control local breeding).
   • Joint and soft tissue aspirations and injections.
   • Minor podiatric procedures, i.e. nail avulsions and phenol matrixectomy.
   • Opthalmic: Cataract extraction, trabeculectomy. The rate of retrobulbar hemorrhage, subconjunctival hemorrhage and mild hyphema increases slightly, but with good prognosis. Risk of bleeding in vitreoretinal, complex lid, and orbital surgical procedures has not been adequately studied.
   • Gastroenterologic: diagnostic esophago-gastro-duodenoscopy (EGD) with or without biopsy, flexible sigmoidoscopy with or without biopsy, colonoscopy with or without biopsy, diagnostic endoscopic retrograde cholangio-pancreatography (ERCP) without sphincterotomy, biliary stent insertion without endoscopic sphincterotomy, endosonography (EUS) without fine needle aspiration, and push enteroscopy of the small bowel. (There is the possibility of poIypectomy with endoscopic examination particularly the colonoscopy. Preparing these cases as high bleeding risk may help prevent repeating the procedure.)
   High risk.
• Cutaneous: More complex procedures, i.e. hair transplantation, blepharoplasty, or facelifts.
• Oral: More complex procedures such as complicated extractions, gingival and alveolar surgeries.
• Opthalmic: Retinal surgery, complex lid and orbital surgery, patients who need retrobulbar anesthesia for ophthalmic procedures.
• Gastroenterologic: Colonoscopic and gastric polypectomy, laser ablation and coagulation, endoscopic sphincterotomy, and those procedures with the potential to produce bleeding inaccessible or uncontrollable by endoscopic means such as pneumatic or bougie dilation of benign or malignant strictures, percutaneous endoscopic gastrostomy, and EUS-guided fine needle aspiration.Intracavitory surgery:
• Intraabdominal surgeries, intrathoracic surgeries, intracranial surgeries,
• Neurosurgical procedures, neuraxial anesthesia and spinal puncture.
• Orthopedic.
• Genito-urinary: Transurethral resection of the prostate?
• Obstetric-gynecologic.
• Cardiac procedures. Pacemaker/ICD insertion have more bleeding potential than bleeding from cardiac catheterization site.
• Any procedures or surgeries that bleeding can not be controlled or stopped with simple intervention.
• Other major surgeries.

Table 10. Protocol for managing anticoagulation during procedures/surgeries (5 plans)

PLAN	PROTOCOL		DAYS OF INADEQUATE ANTICOAGULATION *
1	Continue warfarin		0
2	Hold warfarin	With Pre and Post procedure heparin	1
3	Hold warfarin	With Post procedure heparin	2-4
4	Hold warfarin	With Pre procedure heparin	3-5
5	Hold warfarin only		5-8

* = Mininal days

• #2-#4 = Bridging therapy = use heparin while holding warfarin,The availability of the low molecular weight heparin (LMWH) makes it convenient to use full dose heparin as an outpatient. Remember that the LMWH has a longer half-life than the unfractionated heparin (UFH).
• For more urgent surgery, please review Section "Managing High INR or Bleeding." "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery".

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The section below is for population who require target INR >2.0 (Caucasian). It should be modified for pupulation who require difference target INR.

Detail of protocols for managing anticoagulation during procedures/surgeries (5 plans)

1. Continue warfarin.
   • Check INR 7 days before the procedure, keep INR in low target range. Communicate with operator who will perform the procedure.
   • This protocol will result in no subtherapeutic anticoagulation day.
2. Hold warfarin, post procedure heparin, pre procedure heparin.
• Check INR 7 days before procedure, keep INR in target range.
• Drop INR to 1.5 or less. For INR of 2.0-3.0, it will require about 4(3-5) days. Higher INR will take longer time.
• Start full dose of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) when INR is 2.0 or less which may take about 24-48 hours for INR of 2.0-3.0.
• Check INR 1 day before the procedure. If INR is 1.8 or higher, give vitamin K 2.5 mg orally, or delay the procedure.
• Stop heparin (6 hours for UFH, or 24 hours for LMWH) before the procedure.
• Start full dose of heparin (UFH or LMWH) 24 hours post procedure (when there is no risk of post operative bleeding). No bolus. (This full dose heparin using early postoperatively only apply in patients with low risk for post operative bleeding).
• Low dose (for venous thromboemboli prevention) may be started 12 hours post procedure.
• These post procedure heparin timing should be varied (delayed) depending on risk of bleeding for that patient.
• Restart the previous maintenance dose of warfarin the evening of the procedure. If it cannot be started - see "Remark" below.
• This protocol will result in subtherapeutic anticoagulation for 1-2 days.
3. Hold warfarin, post procedure heparin. (Not suitable for patients with high risk for post procedures/surgeries bleeding)
• Check INR 7 days before the procedure, keep INR in target range.
• Drop INR to 1.5 or less. For INR of 2.0-3.0, it will require about 4(3-5) days. Higher INR will take longer time.
• Check INR 1 day before the procedure. If INR is 1.8 or higher, give vitamin K 2.5 mg orally, or delay the procedure.
• Start full dose of heparin (UFH or LMWH) 24 hours post procedure (when there is no risk of post operative bleeding). No bolus. (Only apply in patients with low risk for post operative bleeding).
• Low dose ( for venous thromboemboli prevention) may be started 12 hours post procedure.
• These post procedure heparin timing should be varied (delayed) depending on risk of bleeding for that patient.
• Restart the previous maintenance dose of warfarin the evening of the procedure. If it cannot be started - see "Remark" below.
• This protocol will result in subtherapeutic anticoagulation for 3-4 days.
4. Hold warfarin, pre procedure heparin.
• Check INR 7 days before procedure, keep in target range.
• Drop INR to 1.5 or less. For INR of 2.0-3.0, it will require about 4(3-5) days. Higher INR will take longer time.
• Start full dose of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) when INR is 2.0 or less which may take about 24-48 hours for INR of 2.0-3.0.
• Check INR 1 day before the procedure. If INR is 1.8 or higher, give vitamin K 2.5 mg orally, or delay the procedure.
• Stop heparin (6 hours for UFH, or 24 hours for LMWH) before the procedure.
• Restart the previous maintenance dose of warfarin the evening of the procedure. If it cannot be started - see "Remark" below.
• This protocol will result in subtherapeutic anticoagulation for 4-6 days.
5. Hold warfarin only.
   • Check INR 7 days before the procedure, keep INR in target range.
   • Drop INR to 1.5 or less. For INR of 2.0-3.0, it will require about 4(3-5)days. Higher INR will take longer time.
   • Check INR 1 day before the procedure. If INR is 1.8 or higher, give vitamin K 2.5 mg orally, or delay the procedure.
   • Restart the previous maintenance dose of warfarin the evening of the procedure, If it cannot be started - see "Remark" below.
   • This protocol will result in subtherapeutic anticoagulation for 6-8 days.

Subcutaneous unfractionated heparin or low dose low molecular weight heparin may be used for prevention of post operative venous thromboemboli.

For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery".Large dose of intravenous Vit K may cause a period of warfarin resistance up to a week, when restart it.

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Table 11. Low bleeding risks: Guidelines for managing anticoagulation during procedures/surgeries.

PROCEDURE/SURGERY	BLEEDING RISK	DIAGNOSIS	THROMBO RISK	PROTOCOL *
(Low bleeding risk)• Cutaneous: Local skin surgery, i.e. Mohs micrographic surgery, simple excisions, biopsy and repairs. • Oral: Simple dental procedures, i.e. simple tooth extraction, dental hygiene, restorations, endodontics, prosthetics and periodontal therapy. (Some dentists give antifibrinolytic agents such as tranexamic acid or Epsilon amino caproic acid mouthwash to help control local bleeding.) • Opthalmic: cataract extractionm, trabeculectomy. • GI procedures: EGD w or w/o biopsy, flex sig w or w/o biopsy, colonoscopy w or w/o biopsy, diagnostic ERCP, biliary stent w/o sphincterectomy, endosonography w/o fine needle aspiration, push enteroscopy of the small bowel. • Miscellaneous: Joint and soft tissue aspirations and injections. Minor podiatric procedures, i.e. nail avulsions and phenol matrixectomy Others:	.	VTE/pulmonary ** emboli	.	.
	Low	--- < 1 month	High	1, (2) †
	Low	--- 1-3 months	High	1, (2)
	Low	--- Recurrent	Low	1, (3,4)
	.	Acute Arterial Emboli	.	.
	Low	--- < 1 month	High	1, (2) †
	Low	--- > 1 month	Low	1, (3,4,5)
	.	Non Valvular atrial fibrillarion (NVAF)	.	.
	Low	Atrial fibrillation	Low	5, (3,4)
	Low	--- With risk factors (1)	High	[1,2,3,4)
	.	Heart Valve Prostheses	.	.
	Low	Bileaflet AV †	Low	5, (2,3,4)
	Low	Other valves, multiple or with additional risk factors (2)	High	[1,2,3,4)
	Low(See "Patients with high, intermediate and low risk for thromboembolism") in "Thromboembolic risk" section above.		Using the above approach as a guide to help select the appropriate protocol for each individual.



• For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery". Large dose of intravenous Vit K may cause a period of warfarin resistance up to a week, when restart it.
• * = In parathesis representing other choices.
• ** = Mechanical methods to help reduce DVT should be applied appropriately.
• (1) = Risk Factors: History of TIAs, CVA, systemic emboli, hypertension, LV systolic dysfunction, recurrent CHF, DM, rheumatic mitral valve disease, CAD, thyrotoxicosis.
• (2) = Risk factors: Atrial fibrillation, severe LV systolic dysfunction, recurrent CHF, previous thromboembolism, and hypercoagulable conditions.
• † = Elective surgeries should be avoided in the first month after an acute venous or arterial thromboembolism. If the surgery is required within 2 weeks after an acute episode of venous thromboembolism and anticoagulation cannot be used, the patient should have venacaval filter inserted.
• †† = St. Jude Medical bileaflet aortic valve, CarboMedics bileaflet aortic valve, Medtronic-Hall tilting disk aortic valve.
• The availability of the low molecular weight heparin (LMWH) makes it convenient to use full dose heparin as an outpatient. Remember that the LMWH has a longer half-life than the unfractionated heparin (UFH).
• If the physician feels that there is a higher chance of significant intraoperative or immediate post operative bleeding associate with continuation of warfarin, he/she may use protocol in the parenthesis.

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Table 12. High bleeding risks: Guidelines for managing anticoagulation during procedures/surgeries.

PROCEDURE/SURGERY	BLEEDING RISK	DIAGNOSIS	THROMBO RISK	PROTOCOL *
(High bleeding risk) • Cutaneous: More complex procedures, i.e. hair transplantation, blepharoplasty, or facelifts. • Oral: More complex procedures such as complicated extractions, gingival and alveolar surgeries. • Opthalmic: Retinal surgery, complex lid and orbital surgery, patients who need retrobulbar anesthesia for ophthalmic procedures. • GI procedures: colonoscopic or gastric polypectomy, laser ablation and coagulation, endoscopic sphincterotomy, pneumatic or bougie dilation of strictures, percutaneous endoscopic gastrostomy, EUS-guided fine needle aspiration. • Cardiac procedures: Pacemaker/ICD insertion have more bleeding potential than bleeding from cardiac catheterization site. • Intracavitory surgery:Intraabdominal surgeries, intrathoracic surgeries, intracranial surgeries, • Neurosurgical procedures, neuraxial anesthesia and spinal puncture. • Orthopedic. • Genito-urinary: Transurethral resection of the prostate? • Obstetric-gynecologic. • plastic surgery. • Any procedures or surgeries that bleeding can not be controlled or stopped with simple intervention. Others:	.	VTE/pulmonary emboli **	.	.
	High	--- < 1 month	High	2 †
	High	--- 1-3 months	High	[4,2)
	High	--- Recurrent	Low	[5,4)
	.	Acute Arterial Emboli	.	.
	High	--- < 1 month	High	2, (4) †
	High	--- > 1 month	Low	4, (5)
	.	Non Valvular atrial fibrillarion (NVAF)	.	.
	High	Atrial fibrillation	Low	5, (4)
	High	---With risk factors (1)	High	4, (2)
	.	Heart Valve Prostheses	.	.
	High	Bileaflet AV ††	Low	5, [4]
	High	Other valves, multiple or with additional risk factors (2)	High	2, (4)



• For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent INR reversal before procedure/surgery". Large dose of intravenous Vit K may cause a period of warfarin resistance up to a week, when restart it
• * = In parathesis representing other choices.
• ** = Mechanical methods to help reduce DVT should be applied appropriately.
• (1) = Risk Factors: History of TIAs, CVA, systemic emboli, hypertension, LV systolic dysfunction, recurrent CHF, DM, rheumatic mitral valve disease, CAD, thyrotoxicosis.
• (2) = Risk factors: Atrial fibrillation, severe LV systolic dysfunction, recurrent CHF, previous thromboembolism, and hypercoagulable conditions.
• † Elective surgeries should be avoided in the first month after an acute venous or arterial thromboembolism. If the surgery is required within 2 weeks after an acute episode of venous thromboembolism and anticoagulation cannot be used, the patient should have venacaval filter inserted.
• †† = St. Jude Medical bileaflet aortic valve, CarboMedics bileaflet aortic valve, Medtronic-Hall tilting disk aortic valve.
  The availability of the low molecular weight heparin (LMWH) makes it convenient to use full dose heparin as an outpatient. Remember that the LMWH has a longer half-life than the unfractionated heparin (UFH).
• Note that protocols with post operative full dose heparin (#2, #3) are associated with more post operative bleeding and should be use when the risk of thromboemboli is significantly out weigh the bleeding problem. If these protocols are used, starting the full dose heparin should be delayed up to 24-48 hours.. This approach may not be beneficial in case the warfarin can be started early.
• Post operative SC heparin may be helpful in prevention of post operative venous thromboembolism with less bleeding complication.

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Table 13 Simple guidelines for managing anticoagulation during procedures/surgeries.

Adapted from Kearon C, Hirsh J. Management of Anticoagulation Before and After Elective Surgery. NEJM 1997; 336: 1506-1511.

CONDITIONS	PRE PROCEDURE	POST PROCEDURE
Acute VTE	.	.
-- Month 1	Heparin (2)	Heparin (2)
-- Month 2-3	.	Heparin (2)
Recurrent VTE	.	SC heparin (3)
Acute arterial embolism	.	.
-- Month 1	Heparin (2)	Heparin (2)
Mechanical heart valve (1)	.	SC heparin (3)
NVAF (1)	.	SC heparin (3)

• No detail in managing patients with different operative bleeding risk, or patients with different thromboembolic risk.
• VTE = Venous thromboembolism.NVAF = Non valvular atrial fibrillation.
• (1) = For low bleeding risk patients.
• (2) = Unfractionated (UFH) or low molecular weight heparin (LMWH).
• (3) = For prevention of venous thromboembolism only.

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• Remark.
• Low molecular weight heparin (LMWH) can be used as an outpatient. Enoxaparin (Lovenox) is most commonly used. There are other preparations with different dose arrangement. Check with third party payment when used as an outpatient.
• If warfarin cannot or should not be restarted in the evening of the procedure, restart it when possible and safe.
• Heparin should cover for late warfarin start and continue until INR reach target range for 2 days.
• Post procedure heparin and warfarin should be started only when there is no more threatened bleeding situation or evidence of bleeding.
• Full dose of heparin should not be start before 12 hours post procedure and no bolus.
• Pre procedure heparin causes less bleeding problems if it is stopped at appropriate time prior to the procedure/surgery.
• There is more bleeding risk from post procedure heparin, particularly if it starts too soon.
• Following an acute episode of venous thromboemboli, any procedures or surgeries should be deferred, if possible, for 1 month and preferably 3 months.
• Patient with post procedure high risk of bleeding and can not receive anticoagulation treatment but require surgery with in 2 weeks after the acute episode of venous thromboemboli, should have venacaval filter inserted.

Using Heparin for "Bridging Therapy"

Unfractionate heparin (UFH) (Update soon)

• Molecular weight of 3000 to 30000 and mean of 15000
  

LMWH (Low molecular weight heparin)

• Molecular weight of 2000 to 9000 and mean of 4000-5000.FDA has not approved for anticoagulation bridging therapy, but there has been sufficient data that it can be used effectively and safely.
• When compare to UFH, LMWH has better bioviability, more predictable dose responses and longer plasma half-lives. It has less interaction with platelets, endothelial cells. macrophages and plasma proteins, less heparin-induced thrombocytopenia (HIT) than UFH (1% vs 3%), and similar rate of bleeding to UFH.
• Can be given subcutaneously on an outpatient basis. It will require adequate plan and patient education to make it work properly.

Unsuitable conditions for LMWH:

• Allergy
• Weight >150 kg.
• Pregnant woman with mechanical valve, unless it can be monitored with anti Xa level.
• History of bleeding disorder of intracranial hemorrhage. GI bleeding within the last 10 days. Major trauma or stroke within the past 2 weeks.
• Cr Cl <30 mL/minute.
• History of heparin-incuced thrombocytopenia of severe thrombocytopenia.
• Potential for medication noncompliance or unsuitable home environment to support therapy
• Severe liver disease
  

Dosing

• Low or prophylactic dose
• High or therapeutic dose

Prophylactic doae	Therapeutic dose
.	.	q 12 hours	q 24 hours
Enoxaparin	20-40 mg od	1 mg/kg	1.5 mg/kg
Delparin	5000 IU od	100 IU/kg	200 IU/kg
Nadroparin	38 IU od	87 IU/kg	.
Tinzaparin	4500 IU od	175 IU/kg	.

Before surgery dosing. Usually start 24-48 hours after last warfarin dose.

• Enoxaparin (Lovenox) 1mg/kg SC q 12 hours or 1.5 mg/kg SC q 24 hours.Dalteparin (Fragmin) 120 U/kg SC q 12 hours or 200 U/kg SC q 24 hours
• Tinzaparin (Innohep) 175 U/kg SC q 24 hours

After surgery dosing

• Therapeutic dose at no sooner than 24 hours after the procedure. Prophylactic dose may be started 12 hours after the procedure in not high bleeding risk patients.
• Continue heparin therapy until INR reaches therapeutic level for 2 consecutive days.

Heparin-induced thrombocytopenia (HIT)

• Incident of 3% from UFH and 1% from LMWH. May associate with thrombosis in 30-80% of the cases.
• May occur as early 1 day into therapy particularly in case with previous heparin exposure.

 

Table 15. Form for managing anticoagulation during procedures/surgeries.

Section A		Section B
Patient name:		.
Age:	Rec No:	.
.		(Circle H or L)
1ry Diagnosis:		Thrombo risk: H, L*	Bleeding risk: H, L*
2ry Diagnosis:		Thrombo risk: H, L*	Bleeding risk: H, L*
Procedure/surgery:		Thrombo risk: H, L*	Bleeding risk: H, L*
Section C.
Select the protocol - Plan 1, 2, 3, 4, 5 (Circle the number)

* H = high, Low = low.

(For more urgent surgery, please review Section Managing High INR or Bleeding, "8. Patient who requires more rapid or urgent reversal before procedure/surgery".)
1. Fill in the patient information in Section A. 1ry Diagnosis = Diagnosis that requires anticoagulation. 2ry Diagnosis = Diagnosis(es) that may increase thromboembolic or bleeding risks.
2. Determine thromboembolic and bleeding risk in Section B. Then circle the H (high) or L (low). Using Table 9, Table 11, Table 12. for risk stratification.
3. Select the protocol plan. Using Table 11, Table 12, Table 10, and individualization for selection guidelines. Then circle the protocol plan number in Section C.
4. May print "Managing anticoagulation during procedures/surgeries section". M ay also mark those areas picked (underline or yellow mark). May send this marked printout to primary physician or place it in the chart.

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Anticoagulation Guidelines for Endoscopic Procedures. A simple guide

	Condition Risk for Thromboembolism
Procedure Risk for Hemorrhage	High	Low
High	- Hold warfarin for 3-5 days - Consider haparin while INR is sub therapeutic *	- Hold warfarin for 3-5 day - Re-institute warfarin right after the procedure
Low	- No change in anticoagulation - Elective procedures should be delaye while INR is in supratherapeutic range

* Use more detail guidelines for heparin bridging as described in the earlier section.

Procedures Risk for Hemorrhage
High Risk	Low Risk
Polipectomy	Diagnostic: OGD +/- biopsy, flex sigmoidoscopy +/- biopsy, colonoscopy +/- biopsy
Billiary sphincterotomy	ERCP without sphincterotomy
Pneumatic or bougie dilatation	Billiary/pancreatic stent without sphincterotomy
PEG placement	Endoscopy without fine needle aspiration
Endosonic guided fine needle aspiration	Endoscopy
Laser ablation and coagulation
Treatment of varices

Conditios Risk for Thrombo-embolism
Hgh	low
Atrial fibrillation with valvular heart disease or prior thromboembolic event	Deep vein thrombosis
Mechanical valve in mitral position	Uncomplicated or paroxymal non-valvular atrial fibrillation
Mechanical valve and prior thromboembolic event	Bioprosthetic valve
Very recent thromboembolic event or multiple and severe thromboembolic events	Mechanical valve in aortic position

 

Anticoagulation in pregnacy

• Warfarin can cross placenta. Its use in the first trimester of pregnancy is associated with embryopathy characterized by nasal hypoplasia, stippled epiphysis or both. (Heparin does not cross placenta).
• LMWH has been associated with mechanical prosthetic valve thrombosis in pregnant woman. The etiology is unknown, possible inadequate dosing during pregnancy.

Options of anticoagulation management in pregnancy with mechanical prosthetic valve.

1. Warfarin throughout pregnancy, with its potential fetal risks. Change to heparin (UFH or LMWH) at 38 weeks, Labor induction at 40 weeks of gestation.
2. Heparin throughout pregnancy, with its associated maternal thrombosis risks particularlly mechanical heart valve prosthesis. It is anticipated that heparin dose in the third trimester will be higher.
3. Heparin during the first trimester. Switch to warfarin in the second trimester. Change back to heparin at 38 weeks. Labor induction at 40 weeks of gestation. Heparin dose in the third trimester is usually higher.

For UFH, start with total daily dose of 35000 U given subcutaneously twice a day. Monitor PTT at least twice a week to keep the level at least 2-3 times of control. For LMWH such as Lavenox, start with 100 mg given subcutaneously twice a day. Monitor anti-Xa to keep the level at 0.5 -1.2 U/ml 4-6 hours after innection.

Risk of mechanical heart valve prosthesis thrombosis in pregnancy continue to be high with heparin therapy. The heparin dose should be kept at high PTT or anti-Xa level, carefully.

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