Table 1.
American Society of Regional Anesthesia guidelines for anticoagulant and antiplatelet drugs
|
Medication
|
Minimum time between last dose of medication and neuraxial injection or catheter placement
|
Minimum time after nerve/neuraxial cathether placement and administration of drug
|
Minimum time between last dose of drug and cathether removal
|
Minimum time between neuraxial injection or cathether removal and administration of drug
|
| Anticoagulants for venous thromboembolism prophylaxis | ||||
| Enoxaparin (Lovenox); prophylaxis, once daily | 12 h | ≥ 12 h | ≥ 12 h | 4 h |
| Enoxaparin (Lovenox); prophylaxis, b.i.d. | 12 h | Contraindicated while catheter in place | 4 h | |
| Heparin SQ; prophylaxis; low-dose, b.i.d. and t.i.d. | 4-6 h | Immediately | 4-6 h | Immediately |
| Heparin SQ; prophylaxis; higher-dose, b.i.d. and t.i.d. | 12 h and assessment of coagulation status | Safety of indwelling catheters has not been established for doses > 5000 Units SQ or total daily dose > 15000 Units SQ. Risk/benefit assessment required | Immediately | |
| Dalteparin (Fragmin); prophylaxis, once daily | 12 h | ≥ 12 h | 12 h | 4 h |
| Anticoagulants at therapeutic doses | ||||
| Heparin IV; full Dose | 4-6 h and normal coagulation status | 1 h, with close monitoring | 4-6 h and normal coagulation status | 1 h |
| Heparin SQ; therapeutic dose | 24 h and assessment of coagulation status | Contraindicated while catheter in place | Immediately | |
| Enoxaparin (Lovenox); therapeutic dose | 24 h, consider checking anti-factor Xa level | Contraindicated while catheter in place | 4 h | |
| Apixaban (Eliquis) | 72 h | Contraindicated while catheter in place | 6 h | |
| Rivaroxaban (Xarelto) | 72 h | Contraindicated while catheter in place | 6 h | |
| Warfarin (Coumadin) | 5 d and normal INR | Variable instructions regarding management of catheter | Immediately | |
| Anti-platelet medications | ||||
| NSAID’s | No restrictions, may increase risk of bleeding | |||
| Aspirin | No restrictions, may increase risk of bleeding | |||
| Plavix | 5-7 d | 24 h postoperatively; catheter may be maintained for 1-2 d due to delayed antiplatelet effect | Immediately if no loading dose given | |
| Ticlodipine (Ticlid) | 10 days | 24 h postoperatively; catheter may be maintained for 1-2 d due to delayed antiplatelet effect | Immediately if no loading dose given | |
| Ticagrelor (Brillinta) | 5-7 d | Contraindicated while catheter in place | Immediately if no loading dose given | |
NSAID: Non-steroidal anti-inflammatory drug.