Anticoagulation

1. Continue Aspirin at all doses
2. Warfarin

i.Hold Warfarin, give Vitamin K 5mg PO x 1 ASAP

ii.Type and cross for 2 units FFP

iii.Goal INR for OR is 1.5 or less for surgery, Goal INR for neuraxial anesthesia is 1.3 or less

iv.Re-check INR 12 hours after vitamin K dose

v.Can proceed with surgery if INR 1.8 or less and patient can get FFP on the way to the OR (patient will receive GETA)

3. Clopidogrel, prasugrel, ticagrelor, cilostazol

i.Continue any Acute Coronary Syndrome (treated medically or with stent) within last 12 months

ii.Continue if drug-eluding stent in last 6 months (in non-ACS)

iii.Continue if bare metal stent within last 1 month (in non-ACS)

iv.No need to delay surgery (patient will receive GETA)

4. NOACs (dibigatran, rivaroxaban, apixiban, edoxaban)

i.Hold, record time of last dose taken clearly. Clearance dependent on renal function.

ii.Generally hip fracture surgery with general anesthesia only can be undertaken 24 hours after last dose for all medications and normal renal function (48 hours for Dabigatran and Apixiban and high risk of bleeding). Risks and benefits should be weighed by teams (ortho, medicine, geriatrics, and anesthesia) for delaying surgery more than 24 hours.

5. Bridging

i.Bridging therapy with heparin indicated if any of the very high risk conditions below:

ii.Very high risk conditions

1. Mechanical heart valve
   1. Mitral prosthesis
   2. Caged ball/tilting aortic prosthesis
   3. Stroke/TIA within 6 months
2. Atrial Fibrillation
   1. CHADS-VASC score 7-9  + absence of additional bleeding risk
   2. Stroke/TIA or systolic embolism within 3 months
3. VTE
   1. VTE within 3 months
   2. Severe thrombophilia
   3. History of VTE during discontinuation of anticoagulation