What is the perioperative anticoagulation management of patients with previous arterial embolism?

Updated: May 08, 2018
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: William A Schwer, MD  more...
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Answer

Answer

Several protocols have been developed to care for patients taking oral anticoagulants. Regardless of the protocol used, the period of subtherapeutic oral anticoagulation should be kept to a minimum in patients with previous embolism and in others who are at highest risk for embolism. Kearon formulated a preoperative and postoperative strategy divided into sites of embolic disease. [13] His recommendations are summarized below.

Arterial thromboembolism

In patients with previous arterial embolism, only 4 daily doses of warfarin should be withheld preoperatively and the INR should be measured the day before surgery to determine if a small dose of vitamin K is needed to accelerate the reversal of anticoagulation. If the INR is more than 1.7 on the day before surgery, administer 1 mg of vitamin K subcutaneously and repeat the INR the morning of the surgery. If on the day of surgery the INR is 1.3-1.7, administer 1 unit of frozen plasma; administer 2 units of frozen plasma if the INR is 1.7-2. The active reversal of oral anticoagulants should be discouraged in patients with mechanical valves, especially with the use of fresh frozen plasma.

For a patient who has had an arterial thromboembolism within a month of surgery, start intravenous UFH when the INR drops to less than 2 to minimize the risk of recurrent embolism. Discontinue the intravenous heparin 6 hours before surgery.


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