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Thread: Perioperative management of patients who are receiving warfarin therapy

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    PharmD Year 1 TomHsiung's Avatar
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    Default Perioperative management of patients who are receiving warfarin therapy

    Key Questions
    • How to stratify patients according to risk for thromboembolism and bleeding?
    • When is preoperative interruption of warfarin therapy not required?
    • If warfarin interruption is required, when should it be stopped and resumed?
    • If warfarin therapy is stopped, when is heparin bridging required?
    • How should heparin bridging be given before and after surgery, and at what dose?


    Question 1
    Overall, an assessment of the absolute risk for thromboembolism should consider 1) the underlying disease requiring anticoagulation, 2) presence of concomitant cardiovascular risk factors, and 3) type of surgery.

    Rather than attempt a bleeding risk classification to encompass all surgery types, clinicians may focus on surgeries associated with a high risk of bleeding, as listed here, in which perioperative anticoagulation should be used with caution:
    • coronary artery bypass, heart valve replacement, intracranial surgery, or intraspinal surgery, in which surgical site bleeding can have serious consequences
    • major vascular surgery such as aortic aneurysm repair and peripheral artery bypass, in which extensive vascular tissue damage predisposes to bleeding
    • major orthopedic, reconstructive plastic, and major cancer surgery, in which the extent of tissue injury predisposes to bleeding
    • urogenital surgery (prostate and bladder resection), in which endogenous urokinase promotes bleeding


    There are also more minor procedures that confer an increased risk for bleeding:


    • colon polypectomy, in which the polyp stalk transection site (especially if > 1 cm in diameter) may have ongoing bleeding that worsens with re-anticoagulation
    • biopsy of prostate or kidney, in which endogenous urokinase may promote bleeding, possibly for several days after a procedure
    • cardiac pacemaker or defibrillator implantation, in which unopposed tissue layers of the pacemaker pocket heal by secondary intent
    Last edited by TomHsiung; Tue 25th April '17 at 9:45pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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