Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia
Insertion, removal or presence of a catheter in selected sites can place a patient who is receiving an antithrombotic agent
at risk for a local bleeding complication, including a neurologic injury such as paraplegia causing bleeding and
development of a spinal hematoma. The timing of epidural catheter manipulation relative to the prior administration time
of an anticoagulant is critically important, and removal of the catheter must occur when the patient is the magnitude of
any antithrombotic effects in the blood is minimal and associated with a low risk of bleeding.
Prior to manipulation (insertion or removal) of a catheter in the epidural space, it is the responsibility of the nurse and/or
physician who is responsible for the management of the epidural catheter (= the anesthesiology pain service or a health
care provided designated by the anesthesiology pain service) to determine if the patient is receiving any antithrombotic
therapy (heparin, low molecular weight heparin, other Factor Xa inhibitors, direct thrombin inhibitor, warfarin, aspirin,
GPIIb/IIIa antagonists, ADP P2Y12 receptor inhibitor, NSAIDs, etc.).
For all patients who are receiving an antithrombotic agent, the planned time of catheter removal or insertion should occur
when the planned pharmacological effect is minimal and below the threshold associated with causing bleeding. The
management of catheter removal should be based on a directly discussion between the primary care team and the acute
perioperative pain service (pager 816-6915). As a general rule, the patient must either be off antithrombotic therapy or
the effect of the antithrombotic agent should be negligible at the time of catheter insertion or removal. The attached
guidelines make specific timing recommendations. These precautions do not apply to most peripheral nerve block
catheters. Should a once daily parenteral anticoagulant be in use, adjust the administration time to 2100 when possible.
Procedures involving closed areas such as the selected ocular, pericardial, spinal or CNS regions are considered high risk
for major bleeding in a patient on antithrombotic therapy. If the risk of bleeding associated with a procedure or the need
for neuraxial anesthesia outweighs the estimated risk of acute thrombosis, holding the antithrombotic agent for a longer
period of time before the procedure should be considered.
References:
1. Geerts WH, Bergquist D, Pineo GF, et al. Prevention of Venous Thromboembolism. American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines (8th edition). CHEST 2008;133:Page 382S
2. Various chapters from The American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th
edition) published in 2012 were also reviewed.
3. Horlocker TT, et al. Regional Anesthesia in the patient receiving antithrombotic or thrombolytic therapy. American
Society of regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Regional Anesthesia
and Pain Medicine, 2010;35(1):64-101
4. Horlocker TT. Regional Anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Brit J Anaesth
2011;107:i96-i106
5. Gogarten W, Vandermeulen E, Van Aken H, et al. Regional anaesthesia and antithrombotic agents: recommendations
of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010;27:999-1015.
6. Manchikanti, L et al. Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of
Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy. Pain Physician 2013;
16:SE261-SES318
7. UW Medicine Pharmacy services: Suggestions for peri-procedural management of edoxaban. Suggestion based on
ASRA 2015 Updates.
8. SAVAYSATM (edoxaban) prescribing information. Parsippany, NJ: Daiichi Sankyo Co., LTD; 2015
1
Recommendations For Timing Of Epidural Catheter Manipulation Relative To Use Of Antithrombotic Agents
ANTICOAGULANTS 1
Timing of spinal
needle insertion or
epidural catheter
placement in a
patient who has been
given an
anticoagulant
Catheter
manipulation in the
presence of
anticoagulation
Timing of epidural catheter
removal
(If anticoagulant could not be
avoided while catheter in place)
Minimum time
between epidural
catheter insertion or
removal and
administration of
anticoagulant
PARENTERAL Agents
PROPHYLAXIS Dosing
5,000 units SC q 12 hours - No time restrictions apply 3
For doses over 10,000 units daily, assess on a patient to patient basis
Unfractionated Heparin
5,000 units q12hrs or q8 hrs
Low Molecular Weight
Heparin
Enoxaparin 30mg SC q12h
Enoxaparin 40mg SC q24h
Dalteparin 5,000 units SC
Delay needle
placement for a
minimum of 12 hours4
Pre-operative LMWH
is not recommended
with neuraxial
procedures. 2
q24h
Dalteparin 2,500 units SC
q24h
Fondaparinux 2.5mg
Delay needle
placement for a
minimum of 72 hours 4
Caution with use.
Avoid concurrent use
of twice daily LMWH
Once daily dose is
permitted; avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant.
Can change to twice
daily LMWH once
catheter is removed.
Avoid use if an
epidural catheter is in
place.
UFH or once daily prophylactic
LMWH while the catheter is in
place.
A minimum of 12 hours between
the last dose and catheter removal
is recommended.
Best if catheter removed just
before the next dose, when the
anticoagulant effect is at a
minimum.
Twice daily LMWH can be
initiated after catheter is removed.
Caution: avoid any catheter
manipulation if the patient is
receiving this drug.
In the event fondaparinux was
started and an epidural is in place,
consider waiting 36-48 hours or
longer before removing the
catheter.
4 hours
4 hours
2
THERAPEUTIC Dosing
Unfractionated Heparin (IV
or SC)
Low Molecular Weight
Heparin
Delay needle
placement until the
aPTT is less than 40
seconds and/or greater
or equal to 4 hours post
stopping IV infusion or
greater than 12 hours
post SC dose
Caution; avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant
Delay needle
placement for a
minimum of 24 hours 4
Contraindicated when
an epidural catheter in
place. Can start
LMWH once catheter
is removed.
Delay needle
placement for a
minimum of 72 hours 4
Avoid use if an
epidural catheter is in
place.
Hold infusion 4-6
hours.
Delay until thrombin
time (TT) has
normalized to baseline
Avoid use if an
epidural catheter is in
place.
Enoxaparin 1mg/kg SC q12h
Enoxaparin 1.5mg/kg SC
q24h
Dalteparin 100units/kg SC
q12h
Dalteparin 200units/kg SC
Avoid removal during
anticoagulant treatment. Hold
infusion 4 hours prior to catheter
removal. Consider getting an
aPTT (send priority one).Target
aPTT less than 40 seconds and
greater or equal to 4 hours post
stopping IV infusion or greater
than12 hours post SC dose
Caution: avoid any catheter
manipulation while the patient is
receiving therapeutic
anticoagulation. Use of UFH is
preferred over use of LMWH
while the catheter is in. If LMWH
was started and an epidural is in
place, hold LMWH and wait 24
hours to reach a low
anticoagulant effect before
removal.
4 hours
Caution: avoid any catheter
manipulation if the patient is
receiving this drug.
In the event fondaparinux was
started and an epidural is in place,
consider waiting 36-48 hours or
longer before removing the
catheter.
Caution: avoid any catheter
manipulation if the patient is
receiving this drug.
In the event bivaluridin was
started and an epidural is in place,
consider waiting 4-6 hours then
draw TT. Removing the catheter
can occur when TT has
normalized.
4 hours
4 hours
q24h
Fondaparinux 5mg, 7.5mg,
10mg
Bivalirudin
4 hours
3
ORAL Agents
Warfarin
Dabigatran
Rivaroxaban
Apixaban
Edoxaban
Stop warfarin 5 days prior to
insertion. Assess INR the day prior to
catheter placement Consider 2.5 mg
PO Vitamin. K if INR greater than
1.5. If more urgent reversal needed
with insertion in next 12 hours, can
consider 1mg IV Vitamin K. INR
Target is less than or equal to 1.2.
Contact the anticoagulation service
(816-2568) for assistance.
Stop dabigatran 3 to 5 days prior to
insertion.
- CrCl greater or equal to 50 ml/min:
3 days
- CrCl less than50 ml/min: 4 to 5 das
Do not initiate until
the catheter has been
removed.
If an epidural catheter is in place
after warfarin started, the catheter
should be removed before the
INR exceeds 1.5. Check the INR
(Send STAT or Priority one) prior
to removal.
Can start warfarin
any time after the
catheter has been
removed. Warfarin
NOT
recommended in
patients who have
a catheter in place.
Caution: avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant
4 hours
Dabigatran NOT
recommended in
patients who have
a catheter in place.
Stop rivaroxaban at least 2-3 days
prior to insertion. Consider stopping
at least 4 days prior if patient has
impaired renal function or age greater
than 65.
-CrCl 60ml/min or greater: 2 days
-CrCl 30-59ml/min: 3 days
-CrCl: 15-29ml/min: 4 days
Stop apixaban at least 3 days prior to
insertion.
-CrCl greater than 50ml/min: 3 days
-CrCl less than or equal to 50ml/min:
4 days
Caution: avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant
Stop edoxaban at least 3 days prior to
insertion.
Caution: avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant
Caution: avoid any catheter
manipulation if the patient is
receiving this drug. In the event
dabigatran was started and an
epidural is in place, consider
waiting 36-48 hours or longer
before removing the catheter.
Caution: avoid any catheter
manipulation if the patient is
receiving this drug.
In the event rivaroxaban was
started and an epidural is in place,
consider waiting 18 hours or
longer before removing the
catheter.
Caution: avoid any catheter
manipulation if the patient is
receiving this drug.
In the event apixaban was started
and an epidural is in place,
consider waiting 12-24 hours or
longer before removing the
catheter
Caution: avoid any catheter
manipulation if the patient is
receiving this drug. In the event
edoxaban was started and an
epidural is in place, consider
waiting 12 hours or longer before
removing the catheter after last
administration.2
No specific recommendations for
renal dose adjustments. In general,
edoxaban is not recommended in
patients with CrCL > 95 ml/min.
Caution: avoid any
catheter manipulation
while the patient is
receiving an
anticoagulant
6 hours
Rivaroxaban NOT
recommended in
patients who have
a catheter in place.
No specific
recommendations.
Consider 48 hours
Apixaban NOT
recommended in
patients who have
a catheter in place.
2 hours after
catheter removal.
Edoxaban NOT
recommended in
patients who have
catheter in place.
1. Additional details in the ASRA guidelines are provided in selected situations such as pregnancy, vascular or cardiac surgery.
2. A neuraxial technique is contraindicated in a patient who received LMWH/Fondaparinux/Direct Thrombin Inhibitor pre-operatively. Indwelling
catheters should be removed prior to starting, but may be safely maintained if the patient is receiving prophylactic LMWH.
3. Consider measuring the aPTT in individuals who may have a therapeutic effect when given 5,000 units of unfractionated heparin subcutaneously
such as individuals who are age 80 or older or who weight below 50kg. If the aPTT is above 40 seconds, consider removing the catheter at the time
the next dose is due to be given, and avoid administering the next dose for 2 to 4 hours before restarting.
4. Longer hold periods may be required in patients with impaired renal function or who have a high risk of bleeding and who are at a low risk for
thrombosis.
SC = Subcutaneous; IV = Intravenous; INR = International Normalized Ration; aPTT = activated partial thromboplastin time; h = hours; mg =
milligrams; kg = Kilograms.
4
ANTIPLATELET
Minimum time
between last dose of
antiplatelet agent and
when catheter
placement can occur
Catheter manipulation
in the presence of
antiplatelet therapy
Timing of epidural catheter removal
(If antiplatelet could not be avoided
while catheter in place)
Minimum time between
epidural catheter insertion
or removal and
administration of
antiplatelet agent
PARENTERAL Agents
Abciximab
48 hours
Eptifibatide
8 hours*
CONTRAINDICATED
while catheter in place
Tirofiban
8 hours*
Avoid removal during antiplatelet
treatment. A minimum of 48 hours
between discontinuation of abciximab
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. A minimum of 8 hours
between discontinuation of eptifibatide
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. A minimum of 8 hours
between discontinuation of tirofiban
and catheter removal is recommended.
2 hours
2 hours
2 hours
ORAL Agents
Aspirin/NSAIDs
Aggrenox
(dipyridamole +
aspirin
Dipyridamole
Clopidogrel
No significant risk; no contraindications exist
No significant risk; no contraindications exist
7 days
Prasugrel
7-10 days
Ticagrelor
5 days
Cilostazol
42 hours
Ticlopidine
10 days
Vorapaxar
Minimum hold period
prior to catheter
placement has not been
established
Minimum hold period
prior to catheter
placement has not been
established
Minimum hold period
prior to catheter
placement has not been
established
Anagrelide
Pentosan
No significant risk; no contraindications exist
Avoid removal during antiplatelet
treatment. A minimum of 7 days
between discontinuation of clopidogrel
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. A minimum of 7-10 days
between discontinuation of prasugrel
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. A minimum of 5 days
between discontinuation of ticagrelor
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. A minimum of 42 hours
between discontinuation of cilostazol
CONTRAINDICATED and catheter removal is recommended.
while catheter in place
Avoid removal during antiplatelet
treatment. A minimum of 10 days
between discontinuation of ticlopidine
and catheter removal is recommended.
Avoid removal during antiplatelet
treatment. Minimum hold period
prior to catheter placement has not
been established
A minimum amount of time to safely
remove a catheter has not been
established.
A minimum amount of time to safely
remove a catheter has not been
established.
2 hours
6 hours
6 hours
5 hours
2 hours
Minimum amount of elapsed
time between catheter
insertion or removal has not
been established
Minimum amount of elapsed
time between catheter
insertion or removal has not
been established
Minimum amount of elapsed
time between catheter
insertion or removal has not
been established
* Longer hold periods may be required in patients with impaired renal function or who have high risk of bleeding and who are at a low risk for
thrombosis
Approved by UCDHS Pharmacy & Therapeutics Committee 6/2015.
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