Therapeutic Handbook - GGC Prescribing

Elective admissions – Risk Stratification of Bleeding continuedExtremely high risk of bleeding:1. Neurosurgical interventionsPatients can be classified as to their risk from thrombosis.Low risk of thrombosis:1. Atrial fibrillation with normal heart valves and no previous embolism or stroke2. Single episode of venous thromboembolism > 3 months previously3. Sinus rhythm, tissue heart valve or modern (post-1990) metal aortic valve inserted > 2 monthspreviouslyHigh risk of thrombosis:1. Atrial fibrillation with previous stroke, embolism, heart valve disease or any type of valvereplacement2. Metal mitral valve, any ‘Ball and Cage’ valve, pre-1990 metal aortic valve3. Any artificial valve and previous embolism4. Any heart valve placed within previous 2 months5. Arterial embolism or venous thrombosis within previous 3 months6. Prior recurrent venous thrombosis7. Patient requiring target INR 3 - 48. Prior venous thrombosis and known high risk thrombophiliaElective admissions - management strategyThe general strategy for anticoagulant management is laid out in the following matrix.N.B. Extremely high haemorrhagic risk procedures (e.g. neurosurgery) – consult the appropriatesenior colleague and do not apply this matrix.Cardiovascular SystemLow riskfrombleedingHigh riskfrombleedingLow risk of thrombosisHigh risk of thrombosisIn general continue warfarin therapy unchangedProviso - INR should be checked < 48 hours prior to procedure;It should not be supra-therapeutic and should be < 4Target INR < 1.4 for procedure1. Omit warfarin on day -5 (i.e. 5 days beforesurgery) – see next page2. Give a prophylactic dose of enoxaparin40 mg SC daily at 1800 hours on eachpre-operative inpatient day3. Restart anticoagulation post-operatively –see next pageTarget INR < 1.4 for procedure1. Omit warfarin on day -5 (i.e. 5days before surgery) – see nextpage2. Use high dose heparin bridgingtherapy pre-operatively – seenext page (LMWH) or page 91(UFH*)3. Restart anticoagulation postoperatively– see next pageSome patients or procedures may not be easily classified into the above categories – if so, theyshould be discussed with the relevant senior clinician (e.g. haematologist, cardiologist, surgeon).* UFH – Unfractionated heparinPage 89