Perioperative Safety of Warfarin Therapy and Reversal

Background: Warfarin is the most widely prescribed oral anticoagulant frequently encountered in the patients presenting for both elective and emergent surgery. Maintaining therapeutic levels of warfarin therapy may increase the risk of blood loss and procedural complications, including complications from neuraxial and regional anesthetic techniques. However, in some vulnerable patient groups, discontinuing therapy may result in negative thromboembolic consequences. Objective: To review the published guidelines and supporting data from clinical studies addressing the safe and coordinated management of patients on warfarin therapy who present for perioperative care. Method: This review highlights the most up-to-date research from clinical trials as well as from retrospective studies in addition to multidisciplinary consensus guidelines regarding the safety of warfarin therapy and reversal in the perioperative period. Results: Based on the most up-to-date literature, certain patient groups may be more vulnerable to cessation of warfarin therapy before surgery and there exists a risk stratification algorithm. In many other cases, particularly emergent surgery, it may be necessary to reverse warfarin therapy preoperatively. There are anesthetic, surgical and safety implications in these clinical decision points. Conclusion: With the aging of the United States population, the prevalence of preoperative patients therapeutic on warfarin will continue to increase, necessitating the multidisciplinary and coordinated care of perioperative clinicians to ensure patient safety and optimize clinical outcomes.