Low risk cases High risk cases

•Stop warfarin for 3 days ^dmrt weB in a^am« > 3 days

•Start heparin 5000 u s/c tds ^StoP warfarin > 3 days

20 000 u/day

•Check that INR < 2.0 and •stop heparin 4 hrs pre-op APTT < 45 sec

•Start heparin 6 hrs post-op

•Restart warfarin post-op/ overlap with heparin until INR > 2.5 for 2 days

Fig. 13 Flow chart summarising the management of oral anti-coagulation in intermediate and major surgical procedures.

Stop heparin 4 hours (if LMWH, stop it 12-24 hours prior to surgery depending on dose and type of LMWH) prior to surgery and check that INR < 2.0 and APTT < 45 seconds immediately before the procedure. If not, then it will probably be sufficient to wait for 1 to 2 hours and repeat the tests.

Restart heparin 6 hours postoperatively and re-establish therapeutic levels.

When stable restart warfarin and overlap with heparin for at least 2 days.

Do not give a loading dose and remember that the patient is not eating and vitamin K deficiency may be a problem. Stop heparin when INR > 2.5. If re-operation is possible, continue with heparin.

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