In the patient requiring urgent surgery, the options to treat an elevated INR are fresh frozen plasma and prothrombin concentrate complex. Vitamin K takes 1-2 days to achieve the target INR and is considered an adjunct in this setting. In the case of semi-urgent surgery, vitamin K can reverse the INR in 1-3 days. Oral administration is preferred, and the dose is based on the INR at presentation In elective procedures, Coumadin can be discontinued 5 days prior to surgery to achieve a target INR of 1.3 or less. Bridging therapy with unfractionated heparin or low molecular weight heparin is indicated in patients with a high or intermediate risk of thromboembolism. In patients requiring surgery with a high risk of bleeding, there may be a role for a temporary IVC filter. In general, Coumadin can be restarted on the first post-operative evening at the maintenance dose. Bridging therapy may be used in post-operatively until the INR is therapeutic.