Therapeutic Handbook - GGC Prescribing

Cardiovascular SystemElective admissions - stopping anticoagulation for surgeryN.B. Day zero is the day of the procedure, minus days are days prior to procedure, plus days aredays after the procedure.1. Before surgery – at pre-assessmenti. Ideally the patient should not be first on the operation list – this allows time for a day zero INRto be obtained prior to surgery if required.ii. Day -7 (or earlier) measure INR.iii. Day -5, stop warfarin: i.e. omit 5 doses prior to theatre.iv. If high dose bridging therapy is appropriate follow the protocol below. Use low molecularweight heparin (LMWH) bridging as the method of choice where possible.2. High dose LMWH bridging in the pre-operative periodOur aim is for patients to get this without hospital admission until day -1. Liaison betweenGP practice / district nurse team will usually be required. However, if a patient or carer is well motivatedand safe disposal of sharps is assured then self-administration at home is possible.i. Stop warfarin on day -5: i.e. omit 5 doses prior to theatre.ii. Organise the prescription and administration of:enoxaparin SC 1.5 mg/kg on the afternoon of days -3 and -2 (i.e. between 1400 hoursand 1800 hours) – see notes 1, 2 and 3 on page 92.iii. Prescribe enoxaparin SC 40 mg for 1800 hours on day -1.3. Before surgery - on wardi. Patient should attend ward by 2 pm on day -1 for repeat INR.ii. Obtain INR result that afternoon and if INR > 1.5 administer:vitamin K 1(phytomenadione) IV 1 mg (0.1 ml) as a single dose.(Use an insulin syringe to draw up 0.1 ml before adding to 100 ml glucose 5% bag andadministering over 15 - 30 minutes).iii Recheck INR on day zero at 8 am.Elective admissions – restarting anticoagulation post-operatively• The first principle is do not prescribe any heparin or warfarin if there is evidence of active bleeding.If in doubt seek advice.• Ensure you have read all the accompanying notes prior to prescribing.• Day zero is the day of the procedure, plus days are days after the procedure.Day 0 – All patientsi. Give enoxaparin SC 40mg at 1800 hours (or 4 hours post-op, whichever is later) if nobleeding.ii. Consider restarting warfarin. Restarting warfarin on day zero may be safe for some, as it willtake several days to take affect. Never restart warfarin with an epidural catheter in situ.Page 90Continues on next page