When to resume heparin (unfractionated heparin) infusion after a procedure?

From the Guidelines

Heparin infusion should be resumed 24 hours after a surgery/procedure in patients receiving therapeutic-dose IV UFH bridging for an elective surgery/procedure. This recommendation is based on the most recent and highest quality study available, which suggests resuming UFH 24 hours after a surgery/procedure over resuming within 24 hours 1. When resuming UFH post-operatively, it is recommended to avoid a bolus dose and commence with a lower-intensity infusion that is associated with a lower target activated partial thromboplastin time than that used for initiation of full-dose UFH administration 1.

The decision to resume heparin infusion should be individualized based on patient-specific factors, including the indication for anticoagulation, thrombotic risk, and observed hemostasis at the procedure site. Complete hemostasis should be confirmed before resuming the infusion, and the patient should be monitored closely for signs of bleeding in the hours following reinitiation. The timing balances the risk of thrombotic events from delayed anticoagulation against the risk of procedure-related bleeding complications from premature resumption.

Key considerations when resuming heparin infusion include:

• Avoiding a bolus dose to minimize bleeding complications
• Commencing with a lower-intensity infusion to reduce the risk of bleeding
• Confirming complete hemostasis before resuming the infusion
• Monitoring the patient closely for signs of bleeding after reinitiation
• Individualizing the decision based on patient-specific factors, including thrombotic risk and observed hemostasis at the procedure site 1.

From the Research

Resuming Heparin Infusion After a Procedure

• The decision to resume heparin infusion after a procedure depends on the type of procedure, the patient's risk of thromboembolism, and the risk of bleeding 2.
• For low-risk procedures, such as upper endoscopy with biopsy, colonoscopy with biopsy, or endoscopic retrograde cholangiopancreatography with stent insertion, it is not necessary to adjust anticoagulation 2.
• For high-risk procedures, such as polypectomy, endoscopic sphincterotomy, laser therapy, mucosal ablation, and treatment of varices, warfarin should be discontinued 4 to 5 days beforehand, and heparin infusions may be used to maintain some degree of anticoagulation 2.
• Heparin administration before general surgery is associated with a more than 2-fold reduction in thromboembolic events, with the optimal time to start heparin being 1 to 10 hours before the time of incision 3.
• Continuous heparin infusion after an initial bolus dose during off-pump coronary artery bypass surgery may be associated with better early postoperative outcomes compared to intermittent intravenous heparin 4.

Timing of Heparin Resumption

• The timing of heparin resumption after a procedure is not explicitly stated in the provided studies, but it is generally recommended to resume heparin as soon as possible after the procedure, taking into account the patient's risk of bleeding and thromboembolism 2, 3.
• In patients with a high risk of thromboembolism, heparin may be resumed immediately after the procedure, while in patients with a lower risk, heparin may be resumed several hours or days after the procedure 2, 3.

Dosing and Administration

• The dosing and administration of heparin vary depending on the patient's condition, the type of procedure, and the risk of thromboembolism and bleeding 5, 6, 4.
• Heparin may be administered intravenously or subcutaneously, with the dose adjusted to achieve a therapeutic activated partial thromboplastin time (aPTT) 5, 6.