ANTICOAGULANTS AND SURGERY GUIDELINES

ASPIRIN
CONTINUE PERI-OPERATIVELY (unless neurosurgery, plastic surgery
stop)
(surgical requirements for ceasing aspirin need to be weighed against
the
cardiovascular risks to the patient)

DIPYRIDAMOLE (Persantin, Asasantin = dipyridamole+aspirin)

OMIT 24 HOURS PRIOR TO SURGERY

CLOPIDOGREL (Plavix, Iscover) also Ticlopidine (Tilodene, Ticlid)

CEASE 7 DAYS PRE-OP

EXCEPT FOR STENTS:

1. Drug Eluting Coronary Stent (Taxus, Cypher, Endeavor)
a) < 12 months ago - perform essential surgery only
stay on clopidogrel
consult cardiologist
consider Tirofiban bridging cover if clopidogrel must be stopped to
prevent major surgical haemorrhage

b) > 12 months ago

Minor surgery - stay on clopidogrel
Major surgery - individual patient assessment, jointly by surgeon,
anaesthetist and cardiologist

2. Bare metal stent - Coronary or Vascular

a) < 3 months ago - as per 1a) above

b) > 3 months ago - stop clopidogrel if no other risks (consider aspirin)

3. Carotid Stent
Commence clopidogrel 75 mg/day 1 week pre-op
(Carotid endarterectomy on clopidogrel - replace with aspirin or
discuss case with surgeon)

WARFARIN
CEASE WARFARIN 5 DAYS PRE-OP
(ie. omit for 4 days pre-op as well as day of operation)

CHECK INR is ≤ 1.4 one day pre-op

BRIDGING COVER:
1. HIGH THROMBOEMBOLIC RISK
a) Mechanical Mitral valve replacement

b) Mechanical Aortic valve replacement complicated by:

older generation valve, atrial fibrillation, previous thromboembolism,
left ventricular dysfunction, hypercoagulable state e.g cancer,
infection, pregnancy

consider: continue warfarin, perform surgery at INR of 2.0

otherwise use: enoxaparin (Clexane*) 1 mg/kg SC bd (therapeutic
dose)
_ reduce dose to 40 mg evening before surgery (prophylactic dose)
_ omit morning of surgery
post-op: require full anticoagulation 6-12 hours after surgery
_ if high risk of bleeding - use unfractionated heparin infusion, fully
reversible with protamine in case of bleeding (therapeutic dose)
5000units IV bolus followed by 1000units/hr infusion (25000units
of heparin in 250ml N saline 10ml/hr)
_ if low risk of bleeding - use Clexane 1 mg/kg bd (therapeutic dose)
_ continue until re-warfarinised to therapeutic INR

2. MEDIUM THROMBOEMBOLIC RISK

a) Mechanical Aortic valve replacement (bi-leaflet with none of
risks above)

b) Atrial fibrillation complicated by (CHADS2 score > 2)

previous CVA or
two or more of the following risk factors:
CCF, H/T, age > 75, diabetes

c) DVT / PE < 3 months ago or recurrent

use: enoxaparin (Clexane*) 1.5 mg/kg SC mane (therapeutic dose)

_ reduce dose to 1 mg/kg day before surgery (1/2 therapeutic dose)
_ omit morning of surgery
post-op: Clexane 40 mg 6-12 hours after surgery (prophylactic dose)
_ continue Clexane 40 mg daily if at risk of surgical bleeding
_ otherwise Clexane 1.5 mg/kg daily (therapeutic dose)
_ continue until re-warfarinised to therapeutic INR

3. LOW THROMBOEMBOLIC RISK

If none of the above risks - bridging cover may not be required

Simplified version
All patients cease warfarin 5 days before and check INR <1.4 day
before as per above. (no need for daily INR preoperatively)

High risk
Therapeutic dose clexane > Reduce to prophylactic dose clexane day
before > Omit on day of surgery > Restart therapeutic dose clexane 6-
12hrs post op (unless high risk of bleeding, use UFH instead) >
Continue until therapeutic INR

Medium risk
Therapeutic dose clexane > Reduce to half therapeutic dose clexane
day before > Omit on day of surgery > Restart therapeutic dose
clexane 6-12hrs post op (unless high risk of bleeding, use prophylactic
dose clexane) > Continue until Therapeutic INR

Low risk
No need for bridging cover.

In all cases
Restart warfarin as per preoperative dose (Remember cannot start
alone without heparin)
Must continue heparin for up to 7 days or until therapeutic range
achieved for 48hrs
Daily INR post op, adjust warfarin dose accordingly (if day procedure,
must see GP daily for INR)

Therapeutic dose Heparin

UFH- 5000units IV bolus followed by infusion 1000units/hr (25000 units
of heparin in 250ml of N saline at 10ml/hr)
LMWH (Enoxaparin/Clexane)
SC 1mg/kg/bd OR
SC 1.5mg/kg/daily