Fast Track Reversal

Fast Track Warfarin Reversal in the Peri-operative period.
Information sheet for all staff
PMCC V 4.3.2 Dec. 2011.
This is an information sheet on Fast-Track warfarin reversal for the peri-procedural
management of patients on long-term warfarin.
Complete details regarding the appropriate reversal of warfarin, to achieve normalisation of
the INR, are outlined in the Anticoagulation Guidelines via the PeterMac intranet .
Current guidelines recommend cessation of warfarin 5 days prior to surgery, to allow the
INR to fall spontaneously to within a recommended safe range (i.e. INR3, the patient may need an additional dose of Vit K. This needs to be coordinated
with the haematologist on call.
4. On the morning of surgery, an urgent INR needs to be done at 0700 for morning surgery
or 1100 for afternoon surgery.
The resident will need to follow this up and inform the relevant haematologist/
anaesthetist if INR> 1.5.
This is important in order to avoid cancellation of the case.
5. After surgery, the patient’s warfarin is re-commenced at their usual dose with monitoring
and with/without bridging therapy, until a therapeutic INR is re-established.
The decision to bridge with LMWH would usually be made by the surgical team and a script
for LMWH issued in PAC or post-operatively.
All paper work (including path slips) pertaining to the above will be generated in PAC.
The prescription for Vit KIV will be either brought in by the patient or will be in the patient’s
notes.
This process is designed for peri-operative patients only.
Please read the attached Flow chart and Forms and familiarise yourself with the process.
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Patient Label
Warfarin: Fast Track Reversal
V 4.3.2
To be implemented only on an individual, case-by-case basis.
Not for patients expected to have an epidural.
Caution in patients with coronary stents.
Proposed Date of Surgery ___ / ___ / ___
For Patient’s attention:
It is important that you bring this information sheet to the hospital.
Date: ___ / ___ / ___
1. Take your last dose of Warfarin
Date: ___ / ___ / ___
1. Do Not take any Warfarin
Date of Surgery (D0) ___/___/________
Operation: ________________________
Surgical Registrar:
Surgical Consultant:
PAC Anaesthetist:___________________
PAC Nurse Coordinator:______________
Responsible Haematologist: ____________
2. Please report to the Medical Day Unit ( ground floor) by 1 pm.
If this is a Sunday, report to the Front Desk of the Hospital at 1 pm; you will
be admitted to the Ward.
You will return home that evening after your INR test and Vitamin K injection.
3. If you are being admitted to hospital the day before surgery
( ___ / ___ / ___ ) then please present to the Patient Registration Desk for
admission at 1.00 pm.
Date: ___ / ___ / ___ (Day of your surgery).
1. Do Not take any Warfarin
2. Report to the Day Surgery Unit (Level 1) for a repeat blood test (INR) by:
- 07:00 ( For morning surgery).
- 11:00 ( For Afternoon surgery).NB: PAC please delete # 2 or #3 above)
Following surgery: your Warfarin will be re-initiated either by the ward medical staff or your GP.
You may be prescribed injections of clexane until your INR is in the required range.
Please inform your Warfarin care provider (GP or nurse) about these interruptions to your regime.
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Instructions to ward/DSU/MDU
1. Day before Surgery (D0-1)
a. Patient needs to be admitted to ward (if Day Before Surgery admit) or to
the Medical Day Care unit by 13:00 (D0-1)
b. Draw blood for an INR test (yellow sticker path form):
i. Administer Vitamin K by slow push (over 2-3 min) before
1600.
ii. If the INR result returns >3.0 then ring Nominated
Haematologist for advice.
2. Day of Surgery (D0)
� If surgery is scheduled for the morning then re-check INR by 07:00
� If surgery is scheduled for the afternoon then re-check INR by 11:00
Send as an Urgent lab request (red sticker path form) to allow time for further
Vitamin K dosing. Please inform lab to expect it and the urgency of the result.
1. If INR returns with a value >1.5 then please page Dr. Burbury (or the
Haematologist–on-call) AND the relevant anaesthetist for appropriate
management.
This is important to avoid last minute cancelation of the case!
Postoperative Guidelines (D0+ 1)
1. Admit post operatively only if indicated by surgery or medical issues.
2. Recommence Warfarin (usual dosing schedule) as indicated clinically.
3. Check INR daily/2 nd daily - either in hospital or in the community.
4. Consider bridging therapy with Enoxaparin, in high TE risk groups, until a
stable INR at the desired target range is achieved.
5. Consider co-ordinating postoperative re-warfarinisation with the warfarin care
provider and patient’s GP.
6. Please return this form via internal mail to Kay Kenchington, PAC prior to
discharge of the patient.
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Patient Label
Checklist for Process.
Path Form (INR) #1 (to be drawn Day before Surgery; D0-1) (yellow sticker)
Path Form (INR) #2 (to be drawn Day of Surgery; D0 at 07:00 or 11:00) (red sticker)
Path Form for any other bloods:
Script for Vitamin K (3mg IV over 2-3 minutes)
E-mail patient details to Haematologist (Dr. Burbury or the Haematologist–on-call)
Ensure patient has copy of this information form filled and checked
Place a copy of this form in the Audit Folder
Patients surgery to be scheduled for mid morning or afternoon, when possible
Script for post op clexane (4 days)
Relevant Phone numbers:
1. DSU ext. 3514
2. MDU ext. 1518/1514
3. Path Lab ext. 1530
4. Haematology:
Dr. Burbury (ring mobile via PeterMac switchboard 9656 1111)
On-Call Haematologist (via PeterMac switchboard)
5. Anaesthetics.
Kay Kenchington (pager 1337); Dr. Ismail or On-Call Registrar (via Switchboard)
Audit Information:
To be completed by the haematology/anaesthetic/surgical registrars involved.
Intra-operative blood loss: _______ mL.
Peri-operative blood transfusion: RBC units; FFP units; Platelets
Postop warfarin: Total Dose ( mg) & No. Days ( days) to therapeutic INR
Postoperative complications:
Bleeding: Haematoma; Bleeding; Re-operation for bleeding
Thrombotic: DVT; PE; MI.
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