Procedural Bridging section of this document) o Warfarin dosing may be separated into initial and maintenance phases o. When warfarin therapy is initiated for venous thromboembolism, it should be given the first day, along with a heparin product or f… Anticoagulation Update: DOACs, VTE Guidelines, “Bridging” and iCentra (whew!) BRIDGING: Suggest bridging with warfarin patients only. 6 I. Follow-up in the anticoagulation clinic was scheduled for 1 week after discharge. INTERRUPTION: Recommend interruption of anticoagulation for DOAC patients and suggest interruption of anticoagulation for patients. The Bleeding Risk of Bridging Anticoagulation Often J Am Coll Cardiol. Bridging is in DOAC patients due to the rapid onset and offset. However, the average CHADS 2 score in this study was 2.3, and 90% of patients underwent minor procedures (e.g., endoscopic, dermatologic, or dental procedures, or cardiac catheterization), so whether the results apply to patients with higher CHADS 2 scores or to those undergoing major … Oral Anticoagulation, Aspirin, or No Therapy in Patients With Nonvalvular AF With 0 or 1 Stroke Risk Factor Based on the CHA 2 DS 2 -VASc Score. Keeling D, Baglin T, Tait C et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. As hospitalists, we focus on the stroke risk, and we find that the ACC/AHA guidelines do not recommend bridging for this patient’s type of aortic valve. This article focuses on the common important management questions for which, at a minimum, low-quality … The safety and efficacy of warfarin is critically dependent on maintaining the INR within Bridging Anticoagulation: Primum Non Nocere. This page includes the following topics and synonyms: Perioperative Anticoagulation, Anticoagulation in Surgical Patients, Surgical Patients on Anticoagulation, Coumadin Protocol for the Perioperative Period, Warfarin Protocol for the Perioperative Period, DOAC Protocol in the Perioperative Period, Bridge Therapy Protocol, Bridging Therapy. PMID: 18574269. Bridging Anticoagulation Perioperative and periprocedural anticoagulation management is a constant clinical dilemma for providers. The warfarin anticoagulation for patients with the On-X Mitral Valve is 2.5–3.5 INR, which is the same for all other mitral mechanical valves. Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 1 of 21 Latest version approved by Policy and Guideline Committee on 19 March 2021 Trust Ref: B30/2016 Date of Next Review: April 2024 The American College of Chest Physicians provides recommendations for the use of anticoagulant medications for several indications that are important in the primary care setting. Since then, options for oral anticoagulation have expanded with the addition of four direct oral anticoagulant (DOAC) agents available in the United States. The only guideline that addressed perioperative management of DOACs was the 2018 ASH guideline on management of VTE which was against measurement of DOAC levels prior to procedures. Anticoagulation management (“bridging”) at the time of elective surgery and invasive procedures (adult) guideline Page 1 of 21 Latest version approved by Policy and Guideline Committee on 19 March 2021 Trust Ref: B30/2016 Date of Next Review: April 2024 anticoagulation. the setting of over anticoagulation, is a major concern. Background: Current guidelines recommend bridging anticoagulation in patients undergoing cardiac rhythm device surgery with a “moderate to high risk” of thromboembolism. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various … 2015 Apr, 65 (14) A1-A36, 1385-1496. Douketis JD et al; American College of Chest Physicians. LMWH or UFH should not be resumed at a fixed time after a surgery or procedure without consideration of the... 2. Full-text for Emory users.. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. Patients with atrial fibrillation B. 2015 Sep 22;66(12):1392-403. Bridging in Procedural Management and Reversal Agents. bridging and monitoring as well as many drug-drug and drug-food interactions. Warfarin should be stopped 5 days before surgery. Anticoagulation of Prosthetic Valves Guideline Reference Number P121214(01) Version 2 Issue Date: 20/11/2018 Page 1 of 13 It is your responsibility to check on the intranet that this printed copy is the latest version Anticoagulation of Prosthetic Valves – Guideline Rechenmacher SJ, Fang JC. 2013 R Rayment 180913 2. Adjustment of Dalteparin dose for Long-term anticoagulation is used in relatively large population of patients to treat and prevent thromboembolic events. Enteroscopy, including diagnostic balloon-assisted enteroscopy. … Chronic oral anticoagulation frequently requires interruption for various reasons and durations. anticoagulation service (bleep 1857 for Oxfordshire patients). Keywords anticoagulation, bridging, guidelines, spine surgery, survey, thromboprophylaxis. Download Perioperative Warfarin Bridging Protocol PDF - 431.3 KB. Should bridging anticoagulation be used? (Bridging) CLINICAL GUIDELINE MAY 2018 WARFARIN BRIDGING ASSESSMENT (for patients on warfarin) Follow these and use table 1 below to conduct a bridging assessment: • Step 1: Identify the patient’s indication(s) for anticoagulation in columns 1 and 2. doi: 10.1056/NEJMoa1501035. Baseline hematocrit and q2-5 days during first 2 weeks of LMWH therapy, and prn if bleeding is suspected or confirmed. Professor of Medicine . Gentamicin once daily policy summary. Bridging with parenteral anticoagulation is not recommended for single out-of-range INRs (< 0.5 below range) in patients with a previously stable INR. British Journal of Haematology 2011;154:311–324. Warfarin 'Bridging' Protocol for Elective Procedures. 2,3 There is new evidence to support the use of bridging therapy in a small group of high risk patients which has been outlined in this guideline. He was discharged home with the existing dose of warfarin. The incidence of VTE after spine surgery varies widely, ranging between 0.3% and 31%. antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a heparin product may be recommended for some patients. J Thromb Thrombolysis (2012). Download NOAC bridging PDF - 434.2 KB. We endeavor to present current guidelines for bridging anticoagulation strategies for patients with MHVs undergoing noncardiac surgery, along with additional recommendations that are based on reports of institutional experiences. Direct Oral Anticoagulant (DOAC) 'Bridging' Protocol. University of Utah School of Medicine . Reviewed for applicability to primary care by members of the College of Family Physicians of Canada. Bridging for HIGH RISK mechanical heart valves prior to elective surgery References Baumgartner H, Folk V, Bax JJ. Vancomycin pulsed dosing policy. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. Anticoagulant therapy is complex and associated with substantial benefits and risks. Anticoagulation Centers of Excellence ("ACE") is an educational program intended to ensure that practitioners are informed of the best and safest anticoagulation practices. In 2011 we reviewed clinical updates and controversies surrounding anticoagulation bridge therapy in patients with atrial fibrillation (AF). 32 Anticoagulation Management Tool User Manual March 2010. unknown, anticoagulation with warfarin (INR 2.0 to 3.0), a factor Xa inhibitor, or direct thrombin inhibitor is recommended for at least 3 weeks before and at least 4 weeks after cardioversion. Chart the appropriate timing of preoperative cessation and postoperative resumption of anticoagulants 3. Peri-Operative Management of Anticoagulation and Antiplatelet Therapy Date: 07 October 2016 This guideline will consider whether and when anticoagulants and antiplatelet agents should be stopped before elective surgery and invasive procedures, when agents can be restarted and how to manage patients on these drugs who require emergency surgery. Several observational studies and a meta-analysis have demonstrated consistently low thromboembolism event rates without conclusive benefits from bridging anticoagulation (Table 1). when antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a heparin product may be recommended for some patients.1,2 There is new evidence to support the use of bridging therapy in a small group of high-risk patients which has been outlined in this guideline. If none, the patient is considered “low risk” (see last row of table 1). What are the bridging guidelines for a mechanical heart valve (aortic or mitral) patient undergoing a minor procedure or surgery while on anticoagulants? o Post-procedure bridging with prophylactic LMWH until bleeding risk minimized then transition back to therapeutic dose LMWH o Post-procedure bridging with prophylactic LMWH only o Resumption of warfarin alone with no LMWH/IV UFH - Restart warfarin with 15-20% increase of previous maintenance dose & retest INR within 3-4 days For patients with atrial fibrillation who are receiving warfarin and require an elective operation or other elective invasive procedure, the need for bridging anticoagulation during perioperative interruption of warfarin treatment has long been uncertain.1-3 Guidelines for prescribing, monitoring and management Oral Anticoagulants Guideline for prescribing, monitoring and management V3 Author: Alice Foster, Dr Dasgupta Approved by MCGT October 2015 Review by: October 2018 Algorithm B This regimen is recommended where patient has one or more risk factors and requires rapid anticoagulation . For patients receiving anticoagulation therapy for VTE who survive an episode of major bleeding, the ASH guideline panel suggests resumption of oral anticoagulation therapy within 90 days rather than discontinuation of oral anticoagulation therapy (conditional recommendation based on very low certainty in the evidence about effects ⊕ ). Methods: We performed a monocentric retrospective two-arm matched cohort study. 41 Anticoagulation Management Tool User Manual February 2018. Bridging with parenteral anticoagulation is not recommended for single out-of-range INRs (< 0.5 below range) in patients with a previously stable INR. Moreover, … Gentamicin once daily policy summary. There are more medications for this purpose. The guidelines for antithrombotic therapy in adults and children were developed by an ... • Unfractionated heparin may be used as bridging anticoagulation in hospitalized patients with chronic conditions requiring temporary discontinuation of warfarin. stopping or continuing anticoagulation must be considered. Chest. Guidelines don't encourage TEE before cardioversion in patients who have been on OAC for at least 3 … mechanical valves) bridging anticoagulation with unfractionated heparin or low molecular weight heparin is recommended. MCS - Anticoagulation Guidelines; UW Medicine MCS Program; Peri-Procedural Anticoagulation. Guidelines for prescribing, monitoring and management Oral Anticoagulants Guideline for prescribing, monitoring and management V3 Author: Alice Foster, Dr Dasgupta Approved by MCGT October 2015 Review by: October 2018 Algorithm B This regimen is recommended where patient has one or more risk factors and requires rapid anticoagulation . WHS Clinical Practice Guidelines/Recommendations for Anticoagulation and Antiplatelet Discontinuation Prior to Surgery The following recommendations are collated from available product references, clinical practice guidelines, and available pharmacokinetic data and are meant for informational purposes only. ... Major bleeding is rare with continuation of therapeutic anticoagulation. antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a heparin product may be recommended for some patients. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al. As a result, there was insufficient evidence for practice guidelines which created weak and inconsistent recommendations regarding the need for bridging anticoagulation. They should be helpful in everyday clinical medical decision-making. 1,2 The addition of a daily aspirin at a dose from 75 to 100 mg is also recommended for patients, unless there is a contraindication to the use of aspirin. Uncertainty remains as to whether patients with atrial fibrillation or mechanical heart valves who require interruption of vitamin K antagonists for invasive procedures benefit from bridging with low molecular weight heparin (LMWH) after the procedure.1 2 Many published and diverse protocols and guidelines have sought to address this common clinical problem, and the … Bridging anticoagulation refers to giving a short-acting anticoagulant, typically low-molecular- weight heparin (LWMH), before and after surgery to minimize the time that patients are not anticoagulated, and, thereby, to minimize the risk for thromboembolism. 1. Background. If a critical INR value of <1.5 is obtained for a patient not new to warfarin therapy, the subsequent procedures listed below will be followed. Baseline platelet count, and q2-5 days during first 2 weeks of LMWH therapy. Such conditions Warfarin related Guidelines 1. (7) Thus, recent guidelines have recommended that procedures with a low or very low probability of major bleeding (i.e. The study was terminated early due to a significant reduction in pocket hematoma with uninterrupted anticoagulation, compared to bridging. Background (Why is this document important?) found an odds ratio of 3.6 (95% confidence interval: 1.52 to 8.50) for major bleeding with bridging versus nonbridging, and no significant difference in TE or mortality . In many cases it is necessary to stop the oral anticoagulant (most commonly warfarin) and replace it with low molecular weight heparin (LMWH) until after the procedure. If the patient falls into a ‘high thrombotic risk’ category or has a combination of moderate and low thrombotic risk factors, bridging tinzaparin may be required as the current guidelines for cessation of the DOACS expose some patients to a prolonged period of inadequate anticoagulation. Opioid Equivalence Chart. An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. (BSH) Guidelines Haemostasis and Thrombosis Task Force, BSH Guidelines Executive Committee and by the Haemostasis and Thrombosis sounding board of ... post-operative bridging (i.e. Patients undergoing colonoscopy frequently require antithrombotic therapy for underlying cardiovascular disease. Clinical Learning Day 2016 Introduction. The effect of warfarin is measured by a blood test referred to as INR (international normalised ratio). Algorithm for bridging therapy indication in patients with mechanical valve prosthesis or venous thromboembolism and need of temporary discontinuation of oral anticoagulation according to American College of Chest Physicians 2012 Guidelines for Perioperative Management of the Antithrombotic Therapy (modified from J.D. In the setting of a subtherapeutic INR, a 5-day regimen of enoxaparin therapy was also prescribed as a bridging anticoagulant. INR is a measure of how much longer it takes the blood to clot when oral anticoagulation is used. Anticoagulation Update: DOACs, VTE Guidelines, “Bridging” and iCentra (whew!) 10-13 Although these methodologically weak studies and expert consensus have served as the basis for guideline recommendations, the consensus is beginning to change based on results from the BRIDGE … Available perioperative data are principally generated from RCT substudies and considering the DOAC pharmacokinetics parameters (short time to peak effect and short half-life), periprocedural bridging is usually not required (Dubois et al., 2017). when antithrombotic therapy is halted, periprocedural anticoagulation (bridging therapy) with a heparin product may be recommended for some patients.1,2 There is new evidence to support the use of bridging therapy in a small group of high-risk patients which has been outlined in this guideline. If a critical INR value of <1.5 is obtained for a patient not new to warfarin therapy, the subsequent procedures listed below will be followed. Treatment guidelines. Individual patient Clinically rel-evant bleeding occurred in 17 (0.9%) of 1812 patients studied. Algorithm for ADP Receptor Antagonists. All other procedures – anticoagulation must be stopped. doi: 10.1378/chest.08-0675. present the first randomised controlled trial of the benefits and risks of bridging anticoagulation (Douketis et al. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. Polyps are found in < 50% of cases. Use recent literature data to guide bridging anticoagulation decision making Bridging in Procedural Management and Reversal Agents. Selecting perioperative patients who require bridging and appropriate method of bridging. For patients undergoing elective surgery, the normal procedure is to stop Coumadin for about 2-3 days before surgery and start Lovenox- an injectable anticoagulant that has immediate onset and lasts 12 hours. This is then used for 2-3 days until the Coumadin has worn off and then the Lovenox is discontinued. Algorithm for Dual Antiplatelet Therapy. ASH VTE Guidelines: Anticoagulation Therapy. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. In patients with higher risk or thromboembolic events (e.g. Peer reviewed by Thrombosis Canada clinical guide committee. Warfarin, a vitamin K antagonist, is recommended for the treatment of venous thromboembolism and for the prevention of stroke in persons with atrial fibrillation, atrial flutter, or valvular heart disease. of chronic anticoagulation will be necessary to avoid excessive procedural- or surgical-related bleeding. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). N Engl J … There are undoubtedly some patients at such high risk for recurrent VTE that bridge therapy is a necessary evil, such as those with acute VTE in the preceding month and those with a prior pattern of brisk VTE recurrence during short-term interruption of anticoagulation therapy. Patients with mechanical heart valves Consider prophylactic dose Dalteparin post-operatively as per MTW VTE prevention guidelines 2. Either is an acceptable form of bridging anticoagulation for patients at intermediate or high risk of thromboembolism, but for patients with low thromboembolism risk, the potential bleeding complications of bridging outweigh the possible thromboembolism prevention. Patients at “low risk” are advised to stop oral anticoagulation without bridging to the procedure. Determine whether perioperative interruption of anticoagulation is necessary 2. lines. a “step-up” approach in which prophylactic dosing ofan injectable International Consensus Committee Guidelines 2002 The patient resumed warfarin later on the day of surgery and her INR returned to therapeutic range by postoperative day 5. 2,3 There is new evidence to support the use of bridging therapy in a small group of high risk patients which has been outlined in this guideline. To justify bridging anticoagulation, the risk of TE while off of anticoagulation should be great enough to justify the bleeding risk of bridging. The recent ACCP guidelines on perioperative management of antithrombotic therapy (2008) draw attention to the fact that bleeding in patients who undergo bridging for OAC is an important—but often underestimated—complication . CLINICAL POLICIES, PROCEDURES & GUIDELINES Approved by Quality & Patient Care Committee 7 July 2016 BRIDGING ANTICOAGULATION – PROTOCOL FOR MANAGEMENT OF ANTICOAGULATION IN THE PERIOPERATIVE PERIOD This LOP is developed to guide clinical practice at the Royal Hospital for Women. 1. For patients with AF, there is a paucity of specific data on OAC bridging therapy. Chronic oral anticoagulation frequently requires interruption for various reasons and durations. The guidelines cover the assessment of perioperative thromboembolic risk secondary to the medical condition, the stratification of bleeding risk inherent to the proced-ure and the patient characteristics that modify this risk, the indications for heparin bridging and a recommended heparin bridging protocol, perioperative antithrombotic Comment. Weight Dose for full intensity anticoagulation Dose for VTE prophylaxis < 50 kg: 5mg SQ q24h: 2.5mg SQ q24h: 50-100 kg: 7.5mg SQ q24h: 2.5mg SQ q24h > 100 kg Identify the indications for bridging anticoagulation in three clinical situations A. New research. Monitoring For Initial LMWH Therapy, Including Bridging. Anticoagulation and Antiplatelet Discontinuation Prior to Surgery The following recommendations are collated from available product references, clinical practice guidelines, and available pharmacokinetic data and are meant for informational purposes only. Change in Guideline Recommendations (Only major included) Upgraded to Class I Recommendation Downgraded to Class IIa Recommendation ACC.org/AFCompar e Bridging anticoagulation is the use of heparin (typically low-molecular-weight heparin [LMWH]) to minimize time off anticoagulation … Perioperative Anticoagulation and Antiplatelet Guideline. For Healthcare Professionals. Perioperative anticoagulation plan heart valve INR 3.5. During this periprocedural period, patients will have subtherapeutic anticoagulation for 10–15 days, raising the question of whether pre and postprocedure bridging anticoagulation is warranted to shorten the subtherapeutic anticoagulation interval with the intent of mitigating the risk for perioperative thromboembolism. Algorithm for Aspirin. ABSTRACT The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. Mechanical valves were excluded from the BRIDGE trial, but the PERIOP2 trial includes mechanical valves and will add to the evidence comparing bridging with non-bridging in high-risk patients (estimated study completion date: September 2018). … *After 3 months standard therapy. 2008 Jun;133(6 Suppl):299S-339S. Preoperative anticoagulation guidelines. SITUATIONS COVERED BY THIS GUIDELINE New England Journal of Medicine 2015;373:823–833. Defining the most appropriate management strategy for these patients requires an assessment of the periprocedural risk of thromboembolism and ma… These procedures are guided by the patient- Douketis et al. to stop an anticoagulant, use a bridging medication, or to restart an anticoagulant should be based on organization-approved protocols and evidence-based practice guidelines that address the patient’s bleeding risk and renal function, as well as the half-life of the medication. Professor of Medicine . Clinical Learning Day 2016 Scott C. Woller, MD Co-Director, Thrombosis Program . To provide hospitalists with current data and guidelines regarding perioperative management of anticoagulation with a focus on bridging anticoagulation. Journal of the American College of Cardiology. New guidelines on antithrombotic therapy in stented patients with concomitant atrial fibrillation indirectly indicate that a reconsideration of the use of UFH and LMWH as bridging agents in some cases might be appropriate . Forgoing bridging anticoagulation is safe in many AF patients who require surgery. Anticoagulation Around Invasive Procedures. Most endoscopists remove small ones with snare & without electrocautery. Practitioners are invited to take the assessment survey to gauge their service compared to ideal practices. MCS - Anticoagulation Guidelines; UW Medicine MCS Program; Peri-Procedural Anticoagulation. Low thromboembolic risk: no need for bridging therapy. More than 2.5 million Americans are chronically anticoagulated for indications including venous thromboembolism (VTE), mechanical heart valve(s), or atrial fibrillation (AF).1Each year, ≈10% of these patients require temporary interruption of anticoagulation for an invasive procedure. full dose anticoagulation) is not started until at least 48 hours after high bleeding risk surgery although thromboprophylaxis should be given Long-term anticoagulant therapy is essential for stroke prevention among patients with atrial fibrillation, but increasing evidence also points to substantial risk for adverse events, especially when anticoagulation is temporarily interrupted. The evidence to inform decision making is limited, making current guidelines equivocal and imprecise. While patients with renal impairment have a higher risk of bleeding and dosing of heparins is … For most patients, it is unnecessary to alter anticoagulation or antiplatelet therapy prior to dental intervention. Available perioperative data are principally generated from RCT substudies and considering the DOAC pharmacokinetics parameters (short time to peak effect and short half-life), periprocedural bridging is usually not required (Dubois et al., 2017). However, the risk of thrombosis—with possibly devastating consequences—is increased if antithrombotic agents are held. Guidelines don’t encourage TEE before cardioversion in patients who have been on OAC for at least 3 weeks, the group notes, and policies on TEE use before AF ablation vary widely regardless of anticoagulation status. 1-11 Multiple factors contribute to this heterogeneity. Eur Heart J 2017; 38: 2739-2791 Nishimura RA, RA Otto CM, Bonow RO at al. Bridging Therapy. Target Audience This activity is designed for hospitalists and residents interested in the field of consultative medicine. Introduction. Hence, long years of research ... and drug-drug and drug-food interactions. Guidelines don't encourage TEE before cardioversion in patients who have been on OAC for at least 3 … Guidelines for perioperative management of chronic anticoagulation differ with respect to the specific indication for anticoagulation. 2018 May, 71 (19) A1-A30, e121-e248, 2079-2280. When I was asked about anticoagulation, I found two standards of care: one shared by the hospitalists and cardiologists, the other by the thoracic surgeons. These procedures are guided by the patient- The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. On the morning of surgery, the patient’s INR level was 1.2, which placed her outside of her therapeutic range. anticoagulation therapy • Review guidelines for determining thromboembolic risk • Review recommendations for bridging therapy implementation as clinically indicated • Review cases for appropriate method to manage oral anticoagulation interruption ba sed on risk stratification • Apply case-specific monitoring parameters for Guidelines suggest warfarin be stopped about five days before a major procedure.3 Anticoagulation is resumed when the postoperative bleeding risk is diminished, with full therapeutic effect delayed five to seven days. Clinicians confront numerous practical issues in optimizing the use of anticoagulants to treat VTE. Opioid Equivalence Chart. AHA/ACC guidelines for the management of patients with valvular heart disease. Chronic oral anticoagulation frequently requires interruption for various reasons and durations. Target INR was decreased to 2.0–2.5. doi: 10.1111/j.1365-2141.2011.08753.x Vancomycin pulsed dosing policy. For example, standard guidelines exist for perioperative management of anticoagulation in patients on warfarin to manage atrial fibrillation or a mechanical heart valve. Scott C. Woller, MD Co-Director, Thrombosis Program . 1. EUS without FNA. • The recommended treatment duration is 12 months, and indefinite anticoagulation therapy is suggested • In patients who have recurrent thromboembolic events with a therapeutic INR or other additional risk factors for thrombosis, a target INR of 3.0 (INR range, 2.5 to 3.5) is suggested B. See peri-procedural anticoagulation bridging guidelines for dental procedures and oral surgery. Identify risks and benefits of bridging anticoagulation 3. ERCP without sphincterotomy. Refer to local (Bridging) CLINICAL GUIDELINE MAY 2018 WARFARIN BRIDGING ASSESSMENT (for patients on warfarin) Follow these and use table 1 below to conduct a bridging assessment: • Step 1: Identify the patient’s indication(s) for anticoagulation in columns 1 and 2. Venous thromboembolism (VTE) is a preventable cause of perioperative morbidity and mortality. High-quality anticoagulation management is required to keep these narrow therapeutic index medications as effective and safe as possible. Whether or not to bridge with heparin or other anticoagulants is a common clinical dilemma. Stop warfarin 5 days pre-op aiming for INR
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