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1、诚信 奉献 求精 创新 Warfarin Therapy Warfarin Therapy Management During Invasive Management During Invasive Procedures and SurgeryProcedures and Surgery 急诊外科 张 荣 诚信 奉献 求精 创新 诚信 奉献 求精 创新 Scope Key Recommendations Risks Management 诚信 奉献 求精 创新 Scope Key Recommendations Risks Management 诚信 奉献 求精 创新 Scope This g
2、uideline provides recommendations for the management of warfarin therapy in adults aged 19 years requiring invasive procedures and surgery. Perioperative management of non-vitamin K antagonist oral anticoagulants can be found in BCGuidelines.ca Use of Use of NOACs in Non-Valvular Atrial Fibrillation
3、NOACs in Non-Valvular Atrial Fibrillation. Non-perioperative management of warfarin is covered in BCGuidelines.ca Warfarin Therapy ManagementWarfarin Therapy Management. 诚信 奉献 求精 创新 Scope Key Recommendations Risks Management 诚信 奉献 求精 创新 Key Recommendations Warfarin discontinuation prior to invasive
4、procedures is necessary for all interventional procedures except for minor skin procedures, routine dental work, cataract surgery, endoscopies without biopsy, and percutaneous venous access. For elective procedures, warfarin should be stopped for 5 to 6 days prior to the procedure to allow gradual n
5、ormalization of the international normalized ratio (INR). For urgent procedures, use of prothrombin complex concentrate is highly effective in rapidly reversing warfarin anticoagulant activity and has a duration of action of 6 hours. The use of bridging heparin therapy is dependent on the risk of th
6、rombosis. Discuss the risk of bleeding with the surgeon and anesthesiologist to determine optimal timing for resuming warfarin and bridging heparin therapy after surgery. 诚信 奉献 求精 创新 Scope Key Recommendations Risks Management 诚信 奉献 求精 创新 Risks The management of warfarin therapy in patients undergoin
7、g surgery or other invasive procedures involves a fine balance between the risk of hemorrhage if the procedure was performed while on warfarin, and the risk of thrombosis if warfarin was discontinued. The thrombotic risk in the perioperative period depends on pre-existing conditions, the time since
8、the last episode of thrombosis, and the thrombotic effect of surgery. The risk of hemorrhage in the perioperative period depends on the patients age, associated medical conditions, type of procedure, approach, site, type of incision and closure, and the method of administration of anesthesia and ana
9、lgesia. It is recommended that the anesthesiologist and the surgeon be consulted in determining the hemorrhagic risk 诚信 奉献 求精 创新 Risks Preoperative management of warfarin therapy consists of timely discontinuation of warfarin and replacement (known as “bridging”) with therapeutic low molecular weigh
10、t heparin (LMWH) or unfractionated heparin if the risk of thrombosis is considered to be sufficiently high. Almost all patients will achieve an international normalized ration (INR) of 70 years) will require a longer period of warfarin withdrawal before surgery. Patients with a high risk of thromboe
11、mbolism or stroke may benefit from bridging with heparin during the preoperative period, either as outpatients (LMWH subcutaneously) or inpatients (unfractionated heparin intravenously) by shortening the duration of subtherapeutic anticoagulation. 诚信 奉献 求精 创新 Risks Postoperative management of warfar
12、in therapy consists of re-initiation of anticoagulation. Postoperative anticoagulation increases the rate of major bleeding. Typically, warfarin can resume the evening of or next day after the procedure because the anticoagulant activity is not established for several days. Restarting warfarin may b
13、e delayed in neurosurgical patients, those receiving epidural analgesia and in patients who are bleeding. For patients at high risk of thrombosis, LMWH by injection is given concurrently with warfarin and the overlap is maintained until a therapeutic INR has been reached. LMWH used postoperatively m
14、ay allow earlier discharge of the patient compared with using unfractionated heparin. 诚信 奉献 求精 创新 Risks If urgent or emergent procedures are to be undertaken in 4-5 days and warfarin reversal is required, it may be satisfactory to give 1-2 mg of vitamin K orally in order to expedite the reversal pro
15、cess. When reversal of anticoagulation is required within 6 hours, intravenous vitamin K and prothrombin complex concentrate (PCC) (e.g., Octaplex, Beriplex) is highly effective and is recommended over frozen plasma infusion . 诚信 奉献 求精 创新 Scope Key Recommendations Risks Management 诚信 奉献 求精 创新 Manage
16、ment 诚信 奉献 求精 创新 Management 诚信 奉献 求精 创新 Management 诚信 奉献 求精 创新 Management of Perioperative Anticoagulation 诚信 奉献 求精 创新 Procedures associated with high and low risk for bleeding 诚信 奉献 求精 创新 Pre-existing conditions associated with higher and lower risk of thrombosis 诚信 奉献 求精 创新 Management of Perioperative Anticoagulation 诚信 奉献 求精 创新 Management of P
