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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 4: Post-operative management for procedures with a high risk of bleeding

Do not prescribe anticoagulation (LMWH or warfarin) if there is evidence of active bleeding - if in doubt seek advice. Never restart warfarin with an epidural catheter in situ. 

Post-operative anticoagulation Day 0
Low risk of thrombosis High risk of thrombosis
If adequate haemostasis, consider enoxaparin SC 40mg1 at 6pm (or 4 hours post-op, whichever is later)  If adequate haemostasis, consider enoxaparin SC 40mg1 at 6pm (or 4 hours post-op, whichever is later) 
Post-operative anticoagulation Day +1 and subsequent days
Low risk of thrombosis High risk of thrombosis

Assess bleeding risk daily

If bleeding risk remains high consider enoxaparin SC 40mg1 at 6pm.

If bleeding risk is now low:

  • Day +1 onwards: give enoxaparin SC 40mg1 at 6pm.
  • Continue enoxaparin until INR is ≥2, or patient ready for discharge if sooner
  • Only after any epidural has been removed, restart warfarin as soon as safe and practicable (i.e. adequate gut function) with the patient's usual daily dose and monitor INR daily

Assess bleeding risk daily

If bleeding risk remains high consider enoxaparin SC 40mg1 at 6pm.

If bleeding risk is now low:

  • Day +1 give enoxaparin SC 40mg1 at 6pm. Only after any epidural has been removed, restart warfarin as soon as safe and practical (i.e. adequate gut function) with the patient's usual daily dose and monitor INR daily
  • Day +2: give enoxaparin SC 1mg/kg at 6pm (do not exceed a dose of 150mg)
  • Day +3 onwards: only after any epidural has been removed and haemostasis allows, increase enoxaparin dose to 1mg/kg twice daily (do not exceed single doses of 150mg)2
  • Continue enoxaparin until INR is ≥2
Post-discharge
Low risk of thrombosis High risk of thrombosis
Stop enoxaparin. Arrange INR monitoring as appropriate Continue therapeutic enoxaparin until INR is ≥2. Arrange INR monitoring as appropriate.

Notes

  1. Unless enoxaparin dose requires adjustment due renal impairment in which case refer to Thromboprophylaxis dose guide in renal impairment
  2. For more guidance see 'Heparin Dose Adjustment, Adult Patients with Very High or Low Body Weight' on NHSGGC StaffNet / Acute / Venous thromboembolism / Diagnosis and Treatment [link only active if accessing via NHS computer].

 

Content last reviewed June 2017

Page last updated Feb 2021