How many days should I stop Acitrome (dicoumarol) oral anticoagulation before surgery?

Preoperative Management of Acitrome (Dicoumarol)

Stop Acitrome (dicoumarol) 5 days before surgery for procedures with low-to-moderate bleeding risk, and ensure your INR is <1.2-1.5 before proceeding. 1, 2, 3, 4

Timing Based on Surgical Bleeding Risk

Standard/Major Surgery (Intermediate-to-High Bleeding Risk)

• Stop dicoumarol 5 days before surgery 3, 4
• Verify INR <1.5 for low bleeding risk procedures
• Verify INR <1.2 for intermediate-to-high bleeding risk procedures 1, 2

Minor Procedures (Low Bleeding Risk)

For minor dental, dermatologic, or cataract procedures:

• Either continue dicoumarol with local hemostatic measures, OR
• Stop 2-3 days before the procedure 3

Neuraxial Procedures (Highest Risk)

• Stop 5 days before procedure AND confirm INR ≤1.2 2
• This is the most conservative approach given catastrophic bleeding consequences

Bridging Anticoagulation Decision

High thromboembolism risk patients (CHADS₂ score ≥3, mechanical heart valve, stroke/TIA within 3 months, rheumatic heart disease):

• Start LMWH or UFH when INR drops below therapeutic range 1, 3
• Stop LMWH 24 hours before surgery 1, 3
• Stop UFH 4-6 hours before surgery 1, 3

Low thromboembolism risk patients:

• No bridging recommended 3
• Bridging increases bleeding risk without clear benefit

Postoperative Resumption

Resume dicoumarol 12-24 hours after surgery (evening of surgery or next morning) when adequate hemostasis is established 3, 4:

• Low bleeding risk procedures: 24-48 hours postoperatively 1
• High bleeding risk procedures: 48-72 hours postoperatively 1

If bridging was used:

• Restart LMWH at prophylactic doses for first 24-72 hours 1
• Then increase to therapeutic doses until INR reaches therapeutic range 1
• Continue bridging until INR is therapeutic, then discontinue heparin

Critical Pitfalls to Avoid

1. Don't bridge low-risk patients - Recent evidence shows bridging increases bleeding without reducing thromboembolism 3

2. Don't stop too close to surgery - Stopping <5 days risks inadequate anticoagulation reversal, particularly in elderly patients or those on low warfarin doses 4

3. Don't delay resumption unnecessarily - Delayed restart (>24 hours) increases thromboembolism risk without clear bleeding benefit 4

4. Account for acenocoumarol differences - If using acenocoumarol instead of warfarin/dicoumarol, only 2-3 days interruption needed 2, 4

Special Considerations

The most recent French guidelines 2 from 2025 provide the most conservative neuraxial procedure guidance, while the 2022 ACCP guidelines 4 offer the most comprehensive perioperative framework. Both strongly support the 5-day interruption standard established in 2012 3 and reinforced by the 2014 Canadian guidelines 1.

For patients with renal impairment, hepatic dysfunction, or unclear medication history, measure INR the day before surgery to confirm adequate reversal 2.