Version May 2024
| Anticoagulant | Interval from last dose to placement/removal | Interval from placement/removal to next dose | Notes |
| Warfarin | 4 to 5 days and verify normal INR; no monitoring needed for single dose within 24 hours of placement | Continue regular neurologic evaluation until 24 hours after removal. If dosed with catheter in place, check INR daily and remove when INR <1.5; if INR 1.5 to 3.0, remove catheter with caution, monitor neurologic status until INR stabilized; if INR >3, hold/reduce warfarin dose. Use of other antihemostatic medications that do not influence INR may increase risk of bleeding complications. | |
| Heparin (unfractionated) | When heparin given for >4 days, check platelets (risk of HIT) prior to insertion or removal. | ||
| Intravenous | 4 to 6 hours and verify normal aPTT | 1 hour | Bloody/difficult needle placement may increase bleeding risk with subsequent IV heparin; use with caution. |
| Subcutaneous low dose thromboprophylaxis (5000 units subcutaneously twice per day or three times per day) | 4 to 6 hours or verify normal aPTT | ||
| Subcutaneous higher dose thromboprophylaxis (7500 to 10,000 units subcutaneously twice per day, total daily dose ≤20,000 units) | 12 hours and verify normal aPTT | ||
| Subcutaneous therapeutic (individual dose >10,000 units subcutaneously or total daily dose >20,000 units subcutaneously) | 24 hours and verify normal aPTT | ||
| Low molecular weight heparin (LMWH) | Delay LMWH 24 hours after traumatic placement | Anti-Xa level is not predictive of the risk of bleeding. Do not use with antiplatelet or oral anticoagulant medications as this increases risk of spinal hematoma. Assess platelet count prior to NA for patients who have received LMWH >4 days; SOAP consensus statement and European guidelines do not recommend platelet count. | |
Therapeutic (subcutaneous)
| ≥24 hours, anti-factor Xa level may be helpful* | ≥4 hours after catheter removal | Do not use therapeutic dosing with catheter in place. |
Prophylactic (subcutaneous)
| ≥12 hours | First postoperative dose ≥12 hours after neuraxial procedure; subsequent dose ≥24 hours after the first dose For twice daily dosing: Remove catheter >4 hours prior to first postoperative dose For single daily dose during continuous epidural: Remove catheter 12 hours prior to next dose of LMWH, and subsequent dose should be >4 hours after removal | Do not maintain epidural catheter with twice daily dosing. Epidural catheter may be maintained with once daily dosing, without administration of any other antihemostatic drugs. |
| Anti-factor Xa inhibitors | |||
| Fondaparinux | ASRA: not addressed European guidelines: 36 to 42 hours | 6 hours Remove catheter prior to first postoperative dose | Do not administer with catheter in place. Limited clinical experience. |
| Direct oral factor Xa inhibitors | |||
| Rivaroxaban | 3 days or measure rivaroxaban specific anti Xa level* | 6 hours Remove catheter prior to first postoperative dose | If unanticipated administration of rivaroxaban occurs with catheter in place, withhold further doses and wait 22 to 26 hours to remove catheter, or measure rivaroxaban specific anti-Xa level. FDA: Delay first dose 24 hours after traumatic puncture. |
| Apixaban | 3 days or measure apixaban specific anti Xa level* | 6 hours Remove catheter prior to first postoperative dose | If unanticipated administration of apixaban occurs with catheter in place, withhold further doses and wait 26 to 30 hours to remove catheter, or measure apixaban specific anti-Xa level.* FDA: Delay first dose ≥5 hours after epidural catheter removal; Delay first postoperative dose 48 hours after traumatic puncture. |
| Edoxaban | 3 days or measure edoxaban specific anti Xa level* | 6 hours Remove catheter prior to first postoperative dose | If unanticipated administration of edoxaban occurs with catheter in place, withhold further doses and wait 20 to 28 hours to remove catheter, or measure edoxaban specific anti-Xa level.* |
| Thrombin inhibitors | |||
| Dabigatran | CrCl <30 mL/minute: avoid NA CrCl 30 to 49 mL/minute: 5 days CrCl 50 to 79 mL/minute: 4 days CrCl ≥80 mL/minute: 3 days Renal function unknown: 5 days | 6 hours Remove catheter prior to first postoperative dose | If unanticipated administration of dabigatran occurs with catheter in place, withhold further doses and wait 34 to 36 hours to remove catheter, or measure dTT or ecarin clotting time.* May be reversed with idarucizumab if necessary. |
| Argatroban | Avoid neuraxial techniques | ||
| Hirudin derivative (bivalirudin) | Avoid neuraxial techniques | ||
| Antiplatelet medication | |||
| Platelet P2Y12 receptor blockers | |||
| 5 to 7 days | Without loading dose: immediate With loading dose: 6 hours | Neuraxial catheters can be maintained for 1 or 2 days if no loading dose will be administered. |
| 7 to 10 days | Without loading dose: immediate With loading dose: 6 hours | Neuraxial catheters should not be maintained after administration of prasugrel. |
| 10 days | Without loading dose: immediate With loading dose: 6 hours | Neuraxial catheters can be maintained for 1 or 2 days if no loading dose will be administered. |
| 5 to 7 days | Without loading dose: immediate With loading dose: 6 hours | Neuraxial catheters should not be maintained after administration of ticagrelor. |
| 3 hours | 8 hours Remove catheter prior to first postoperative dose | |
| Platelet GP IIb/IIIa inhibitors | Contraindicated for 4 weeks after surgery; monitor neurologic status if given after neuraxial technique. | ||
| 4 to 8 hours | ||
| 4 to 8 hours | ||
| 24 to 48 hours | ||
| Cilostazol | 2 days | 6 hours Remove catheter ≥6 hours prior to first postoperative dose | |
| Dipyridamole | 24 hours | Remove catheter ≥6 hours prior to first postoperative dose | |
| Aspirin | May continue dosage | May continue dosage | Affects platelet function for the life of the platelet (up to 7 days). Avoid neuraxial techniques on aspirin if early postoperative use of other anti-hemostatic drugs (including heparin) is anticipated. |
| NSAIDs (nonsteroidal antiinflammatory drugs) | May continue dosage | May continue dosage | Effect on platelet function normalizes within 3 days. Avoid neuraxial techniques on NSAIDs if early postoperative use of other anti-hemostatic drugs (including heparin) is anticipated. COX-2 inhibitors (celecoxib) have minimal effect on platelet function. |
| Herbal medications (garlic, ginkgo, ginseng) | May continue dosage | May continue dosage | Concurrent use with other anti-hemostatic drugs may increase bleeding risk. |
aPTT: activated partial thromboplastin time; ASRA: American Society of Regional Anesthesia and Pain Medicine; CrCl: creatine clearance; FDA: US Food and Drug Administration; HIT: heparin-induced thrombocytopenia; INR: international normalized ration; IV: intravenous; NA: neuraxial anesthesia; PT: prothrombin time; P2Y12: purinergic receptor P2Y.
* Safe levels other than zero have not been determined.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
