Different protocals for warfarin reduction

[lance]

Toronto Hospital protocal from 6 days prior to surgery date to 5 days following date of surgery:
Warfarin dropped and LMWH started 5 days prior to surgery.
Day before surgery, nothing. CORRECTED TO SAY DOSE OD not OO. Sorry, misread handwriting.
Day of surgery (6-12 hours post procedure if hemostatis is achieved) 1.5x the daily dose of warfarin and LWMH for the next two days. Resume regular dose of warfarin on day 3 and continue with LMWH until day five post surgery.

The Province of British Columbia recommendation is similar but they don't give LMWH until 48 hours from the last dose of warfarin. They discontinue the LMWH "just before surgery" and start LMWH and warfarin as pre-op dose as soon as possible.

Both reliable sources and a little different fom each other.

So is it better to have the gap in anticoagulation closer to surgery or well in advance?

 

[Ross]

closer to surgery.

 

[Guest]

The two protocols illustrate an important point with warfarin management - there are many right answers and many wrong answers.

The principles that I try to follow are to make small changes in the right direction and treat the person, not the number.

 

[tommy]

Lance,

I prefer a more precise approach instead of estimating (guessing?) how many days it takes for you to dissipate and later absorb Coumadin.

Prior to surgery, I don't start Lovenox until my INR drops below 2.0. After surgery, I stop Lovenox as soon as my INR reaches 2.0. It means a little extra INR testing, but it is more precise. I would rather test a few extra times than take a few extra doses of Lovenox.

I take my last Lovenox 12 hours prior to procedure and start 12 hours after procedure. That leaves a window of 12 hours without anticoagulation protection. Coumadin is also restarted the night of the procedure.

 

[Guest]

It would seem that Tom's method would always be better but the sad fact is that there is no way to predict who will bleed on Lovenox and these are among the worst outcomes. The outcome does not seem to be related to the method of bridging, it seems to be that maybe the skill of the surgeon or possibly chance is the major determinant. Precision does not add to the risk but it certainly does not eliminate it.

 

[tommy]

Al,

You are correct about the bleeding. I have a tendency to bleed at the surgery site just as much on the day before I go off Lovenox than the day after surgery. It's that double dipping with the Lovenox and Coumadin. I just lay low until I'm off the Lovenox. It's the medicine I love to hate, but it beats the alternative.