Heparinisation regime

1. Admit patient and stop warfarin 2 –3 days before operation.

2. Concurrently place an iv cannulae and set up a syringe pump with 30,000iu heparin in 0.9% saline to run over 24 hours (48mls @ 2mls/hour).

3. Check the APTT after 6 –12 hours and adjust the heparin dose accordingly. The KCCT should be stabilised at 2.0 to 2.5 time control after 24 hours.

4. Continue infusion until 2 hours pre-op. Recommence warfarin and heparin after surgery. Continue infusion until INR returns to pre-op levels, which may take several days.

5. Emergency correction of the INR may be achieved by the use of 2 –4 units of Fresh Frozen Plasma, and the INR should be checked after 4 hours to assess the need for further FFP. Vitamin K should be avoided as a dose of 10mg impairs subsequent warfarinisation for several weeks.

6. Protamine Sulphate may be given intra-operatively as an antidote to heparin.

7. 1mg iv neutralises 100iu heparin within 15 minutes.

Required if the INR is too high for relevant surgery of if patient develops a significant DVT or pulmonary embolism.