Perioperative Warfarin Management

1. Emergent surgery: reversal with vitamin K with/without PCC
2. Elective surgery:
   1. Preoperative warfarin interruption depends on risk of procedural bleeding (very low/low vs intermediate/high)
      1. Low → continue warfarin
      2. Elevated → stop warfarin 5 days prior to OR
   2. Perioperative bridging depends on the risk of thromboembolism. In patients with an elevated risk profile, bridging might be a good idea. This would consist of IV UFH or SC LMWH starting Day -3, check INR Day -1, and stop/halve LMWH Day -1. If on UFH, then stop 4 hours prior to OR. Day 0 evening, resume warfarin if patient is tolerating PO. On Day +1 to +3, if hemostasis is achieved, then resume UFH, LMWH, or warfarin. On Day +5 to +6, stop UFH or LMWH when the INR is therapeutic.

References

1. https://www.thrombosiscanada.ca/guides/pdfs/Warfarin_perioperative_management.pdf