If bleeding risk remains high, consider prophylactic dose LMWH at 6pm.  When bleeding risk is low (generally day 2 onwards), proceed as below. 

(If bleeding risk remains high in patients at extremely high risk of thrombosis on day 2, the case should be discussed with a cardiologist to allow the approach to bridging to be individualised). 

• Give prophylactic dose LMWH at 6pm.
• 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. 
• Continue prophylactic dose LMWH until INR is ≥2, or patient ready for discharge if sooner. 

• Give therapeutic dose LMWH at 6pm ensuring 6 hours have elapsed from removal of an epidural if applicable before starting. 
• 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. 
• Continue LMWH until INR is ≥2.

• Give therapeutic dose enoxaparin 1mg/kg TWICE DAILY ensuring 6 hours have elapsed from removal of an epidural if applicable.  Do not exceed single dose of 150mg. 
• 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. 
• Continue enoxaparin until INR is ≥2.

Stop prophylactic dose LMWH on discharge, even if INR not within therapeutic range. Arrange INR monitoring as appropriate. 

Continue therapeutic dose LMWH on discharge until INR is ≥2. Arrange INR monitoring as appropriate. 

Continue therapeutic dose enoxaparin 1mg/kg TWICE DAILY on discharge until INR is ≥2. Arrange INR monitoring as appropriate.