Warfarin Perioperative Management: Bridging & INR Governance
Stop and verify
- Stop warfarin 5 days before the procedure.
- Check INR pre-procedure; target <1.5. If ≥1.5 within 24–48 h of the case, correct or delay.
Who needs bridging?
Bridge **only** when thrombotic risk is high (e.g., some mechanical valves, recent VTE, very high AF stroke risk). If CrCl <30 mL/min, prefer UFH over therapeutic LMWH.
Restart timing (if hemostasis is secure)
- Low/Moderate bleeding-risk procedures: restart ~12–24 h post-op.
- High-risk or neuraxial contexts: restart ~48–72 h post-op.
Neuraxial catheter considerations
Ensure INR <1.5 prior to catheter removal. Coordinate with anesthesia for timing. Warfarin restarts still follow the baseline windows above once hemostasis is secure.
Generate a timestamped plan (including bridging suggestion and INR governance) with the AnticoagPlanner calculator.
Sources
- MD Anderson. Peri-Procedure Anticoagulants, V8 (approved 07/15/2025). Warfarin appendix.
- ASRA/Stanford institutional neuraxial notes (INR & catheter removal).
Disclaimer: Educational content. Supports, not replaces, clinical judgment. Confirm local policy and anesthesia guidance for neuraxial catheters.