Bridging for patients taking warfarin
| Preoperatively |
| Give last warfarin dose on day –6 |
| Start bridging on day –3 with one of the following: Enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily Dalteparin 100 IU/kg twice daily or 200 IU/kg once daily Tinzaparin 175 IU/kg once daily Nadroparin 85 IU/kg twice daily |
| Give last bridging dose on the morning of day –1 |
| Do not routinely check the international normalized ratio on the day before surgery (> 90% will be < 1.5) except for very high-risk cases or patients having neuraxial anesthesia |
| Do not continue aspirin; stop 7 days preoperatively, and resume 7 days postoperatively |
| Give the patient precise instructions for the bridging plan |
| Postoperatively |
| Give double dose of warfarin on the first 1–2 days postoperatively |
| Resume bridging when hemostasis is secured: 24 hours after low-bleeding-risk surgery 48–72 hours after high-bleeding-risk surgery |
| Do not use therapeutic-dose bridging at all for: Cardiac surgery Intracranial or spinal surgery Cancer surgery (eg, Whipple procedure) Reconstructive surgery (eg, skin grafting) |