![]() ![]() LMWH used postoperatively may allow earlier discharge of the patient compared with using unfractionated heparin. 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. Restarting warfarin may be delayed in neurosurgical patients, those receiving epidural analgesia and in patients who are bleeding. 3 Typically, warfarin can resume the evening of or next day after the procedure because the anticoagulant activity is not established for several days. Postoperative anticoagulation increases the rate of major bleeding. ![]() Postoperative management of warfarin therapy consists of re-initiation of anticoagulation. Patients with a high risk of thromboembolism 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. Almost all patients will achieve an international normalized ration (INR) of 70 years) will require a longer period of warfarin withdrawal before surgery. Preoperative management of warfarin therapy consists of timely discontinuation of warfarin and replacement (known as “bridging”) with therapeutic low molecular weight heparin (LMWH) or unfractionated heparin if the risk of thrombosis is considered to be sufficiently high. It is recommended that the anesthesiologist and the surgeon be consulted in determining the hemorrhagic risk. The risk of hemorrhage in the perioperative period depends on the patient’s age, associated medical conditions, type of procedure, approach, site, type of incision and closure, and the method of administration of anesthesia and analgesia. The thrombotic risk in the perioperative period depends on pre-existing conditions, the time since the last episode of thrombosis, and the thrombotic effect of surgery. The management of warfarin therapy in patients undergoing 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.
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