Anti-coagulants What are blood thinners? – to prevent the formation of blood clots. Clots in blood vessels and the heart can cause serious medical attention such as strokes, and heart attacks. Heparin or Warfarin will slow down the body’s process of making clots Who need blood thinners? – heart diseases, atrial fibrillation, heart valve replacement, a risk of blood clots after surgery, and congenital heart defects https://www.stroke.org/en/life-after-stroke/preventing-another-stroke/anti-clotting-agentsexplained - clotting factors are proteins made in the liver. These proteins cant be created in the liver without vitamin K. Generally recommended only for people with strokes caused by clots originating in the heart. *higher risk of serious side effects such as bruising, skin rash, and bleeding in the brain, stomach, and intestines* https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.111.084517 - Bridging Anticoagulation, Is it Needed When Warfarin is interrupted around the time of a surgery or procedure? https://medlineplus.gov/bloodthinners.html - Blood thinners https://www.stgeorges.nhs.uk/wp-content/uploads/2021/06/HAE_SASP_01_LP.pdf - stopping anticoagulants prior to Surgery or a Procedure Articles/journals: 1) https://www.ncbi.nlm.nih.gov/books/NBK557590/ 2) https://ashpublications.org/blood/article/120/15/2954/30631/How-I-treat-anticoagulatedpatients-undergoing-an 3) https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Wordetc/Tools%20and%20Practice%20Support/Quality%20Programs/Anticoagulation-roundtable/4- How-I-Tx-anticoagd-patients.pdf - How I treat anticoagulated patient undergoing an elective procedure or surgery 1) Heparin – Uses: prevents new clots or prevents current clots from getting bigger, treats DVTs, treats pulmonary embolism, treats angina/MI, and givens prophylactically to prevent clots Drugs: heparin, dalteparin, and enoxaparin Antidote – protamine sulfate Therapeutic range: APTT 46-70 seconds, 1.5 – 2.0 times the baseline value

Patient education: educate on bleeding precautions and wear a medic alert device • Avoid NSAIDs, aspirin, antibiotics, and alcohol, gently brush teeth with a soft-bristled toothbrush, avoid contact sports, remove throw rugs (decreased risk for falls), and use an electric razor • Safe to use during pregnancy (Recommendation) – Unfractionated heparin – hold heparin 4 hours prior to surgery Low-Molecular weight Heparin: • daily dosing – administer half the daily dose in the morning of the day prior to the surgery, • Q12h dosing – hold the evening dose the day prior to the surgery 2) Warfarin Uses: Suppresses coagulations by interfering with the production of vitamin K (prevents new clots or prevents current clots from getting bigger) and treats A fib, artificial heart valves, those with a history of thrombosis Drugs: warfarin Antidote – vitamin K Therapeutic range: PT/INR 2-3 & up to 3.5 for heart valve replacement , 1.5-2.0 times the control values • The higher the number, the higher the chance of bleeding Patient education: educate on bleeding precautions and wear a medic alert device • Avoid NSAIDs, aspirin, antibiotics, and alcohol, gently brush teeth with a soft-bristled toothbrush, avoid contact sports, remove throw rugs (decreased risk for falls), and use an electric razor • NOT SAFE during pregnancy • Educate client to be consistent with their vitamin K food intake ( do not increase, decrease, or be inconsistent with the intake of vitamin K foods) • Frequent blood tests to monitor therapeutic levels • Take the medication same time every day! (recommendation) • Hold warfarin at least 5 days before surgery when indicated • Consider checking INR within 24 hours of surgical procedure to ensure that INR goal has been attained. (Consideration)

• Consider 6-7 days with the advanced age of higher INR goals • Consider low-dose phytonadione, if not at goal. (An INR in the normal range is especially important in patients undergoing surgery associated with a high bleeding risk (intracranial, spinal, urologic), if neuraxial anesthesia is to be used **Direct oral anticoagulants Renal function Low Bleeding Risk Procedure High Bleeding Risk Procedure GFR >50 Pre-op: hold 1 day prior to OR Pre-op: Hold 2 days prior to OR Post-op: Resume 1 day after OR Post-op: resume 2-3 days after OR GFR