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
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.