Drug and dose | High risk of bleeding block (neuraxial and deep nerve blocks) | ||
Time from last drug intake to intervention | Target laboratory value at intervention | Time from intervention to next drug dose | |
VKA | Until target laboratory value: (about 3 days acenocoumarol; 5 days warfarin, fluindione; 7 days phenprocoumon) | INR normal | |
DXA low* | 24 hours rivaroxaban, edoxaban (30 hours if CrCl <30 mL/minute), 36 hours apixaban | No testing | |
DXA high | 72 hours or until target laboratory value (until target laboratory value if CrCl <30 mL/minute) | DXA level <30 ng/mL (alternative: ≤0.1 anti-Xa international units/mL) | Low doses: according to guidelines on postoperative VTE prophylaxis¶ (about 8 hours − tmax = 6 hours postoperative). Consider prolonged time interval after bloody tap.Δ |
Dabigatran low* | 48 hours | No testing | |
Dabigatran high | 72 hours or until target laboratory value (until target laboratory value if CrCl <50 mL/minute) | DTI level <30 ng/mL (alternative: thrombin time in normal range of local laboratory) | High doses: according to guidelines on therapeutic anticoagulation◊ (about 24 hours postoperative). |
LMWH low ≤50 anti-Xa international units/kg/day Enoxaparin ≤40 mg/day | 12 hours (24 hours if CrCl <30 mL/minute) | No testing | |
LMWH high | 24 hours (48 hours if CrCl <30 mL/minute) or until target laboratory value (especially if CrCl <30 mL/minute) | ≤0.1 anti-Xa international units/mL | VKA, DOAC, LMWH high, UFH high; should not be administered with a catheter in situ. |
UFH low ≤200 international units/kg/day SC ≤100 international units/kg/day IV | 4 hours | No testing | UFH low: 1 hour for IV in cardiovascular surgery. |
UFH high | Until target laboratory value (about 6 hours if IV, 12 hours if SC) | aPTT or anti-Xa or ACT in normal range of local laboratory | |
Fondaparinux low ≤2.5 mg/day | 36 hours (72 hours if CrCl <50 mL/minute) | No testing | |
Fondaparinux high | Until target laboratory value (about 4 days) | Calibrated ≤0.1 anti-Xa international units/mL | |
Aspirin low ≤200 mg/day | 0 | No testing | Routinely prescribed next time point. |
Aspirin high | 3 days (in normal platelet counts) to 7 days | (Consider specific platelet function tests in normal range of local laboratory) | 6 hours. |
P2Y12 inhibitor | 5 days ticagrelor; 5 to 7 days clopidogrel; 7 days prasugrel; or until target laboratory value | 0-hours clopidogrel 75 mg; 24 hours prasugrel, ticagrelor; 2 days clopidogrel 300 mg. | |
Aspirin low + anticoagulant | Aspirin: 0 + time interval of specific anticoagulant | Specific laboratory test for combined anticoagulant | Aspirin low: routinely prescribed next time point. Combined anticoagulant, antiplatelet drug: according to guidelines on therapeutic anticoagulation, platelet inhibition◊ (about 24 hours postoperative). |
Aspirin low + antiplatelet drug | Aspirin: 0 + time interval of specific antiplatelet drug | (Consider specific laboratory test for combined antiplatelet drug) |
ESAIC: European Society of Anaesthesiology and Intensive Care; ESRA: European Society of Regional Anaesthesia; VKA: vitamin K agonist; INR: international normalized ratio; DXA: direct Xa agonist; CrCl: creatinine clearance; VTE: venous thromboembolism; DTI: direct thrombin inhibitor; LMWH: low molecular weight heparin; DOAC: direct-acting oral anticoagulants; UFH: unfractionated heparin; IV: intravenous; SC: subcutaneous; aPTT: activated partial thromboplastin time; ACT: activated clotting time; EHRA: European Heart Rhythm Association.
* Definitions of low and high DOAC doses:¶ For example, ESAIC guidelines on VTE prophylaxis.[1,2]
Δ Blood in the needle/catheter.
◊ For example, EHRA guidelines.[3]From: Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100. DOI: 10.1097/EJA.0000000000001600. Copyright © 2022 European Society of Anaesthesiology and Intensive Care. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
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