GGC Medicines - Table 3: Pre-operative management for procedures with a high risk of bleeding

Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

Table 3: Pre-operative management for procedures with a high risk of bleeding

Pre-operative anticoagulation Day -5
Low risk of thrombosis	High risk of thrombosis
Stop warfarin (ie omit 5 doses prior to theatre). No pre-op LMWH is required.	Stop warfarin (ie omit 5 doses prior to theatre). Organise the prescription and administration of enoxaparin for days -3, -2 and -1 [ideally organised at POA clinic]¹. The aim is for patients (or carers) to self-administer enoxaparin at home however liaison with district nurse services may be required. Please ensure patients are given a sharps bin to safely dispose enoxaparin syringes.
Pre-operative anticoagulation Day -3 and -2
Low risk of thrombosis	High risk of thrombosis
No pre-op LMWH is required.	Enoxaparin SC 1mg/kg once a day in the morning (between 8am and 10am). Round dose to nearest syringe size. Do not prescribe doses above 150mg enoxaparin without seeking senior advice.
Pre-operative anticoagulation Day -1
Low risk of thrombosis	High risk of thrombosis
Check INR. If INR ≥1.5 administer vitamin K₁ (phytomenadione) IV 1mg (0.1ml) as a single dose².	Enoxaparin SC 1mg/kg once a day in the morning (between 8am and 10am) but omit this if it cannot be administered before 10am. Check INR. If INR ≥1.5 administer vitamin K₁ (phytomenadione) IV 1mg (0.1ml) as a single dose².
Pre-operative anticoagulation Day 0
Low risk of thrombosis	High risk of thrombosis
Ideally, patient should not be 1st on the operating list - this allows time for a day zero INR to be obtained prior to surgery if required. Recheck INR at 8am if not already ≤1.4 on day -1. Target INR for procedure is ≤1.4.

Notes

LMWH should be prescribed and issued from secondary care, and the patient instructed on self-administration. In exceptional circumstances district nurse or treatment room nurse services could be asked to facilitate.
Use an insulin syringe to draw up 0.1 ml before adding to 100ml glucose 5% bag and administering over 15-30 minutes.