Anticoagulant Treatment and Regional Anesthesia

Chapter: Anticoagulant Treatment and Regional Anesthesia
McMaster Section Editor(s): James Douketis
Section Editor(s) in Interna Szczeklika: Krystyna Zawilska†, Anetta Undas, Wiktoria Leśniak
McMaster Author(s): James Douketis
Author(s) in Interna Szczeklika: Anetta Undas, Krystyna Zawilska†
† Deceased.
Additional Information

1. Perispinal hematoma (hematoma of the spinal canal) after a central blockade (ie, epidural or spinal anesthesia) is a rare but serious complication of anticoagulant treatment and antithrombotic prophylaxis.

Risk factors: Impaired hemostasis (including procedures performed at the time of full anticoagulant activity), anatomic abnormalities of the spine, catheter use, traumatic or repeated attempts to introduce a needle or catheter into the spinal canal, and catheter removal at the time of anticoagulant activity.

2. Timing of lumbar puncture, removal of an epidural or spinal catheter, and start of anticoagulant prophylaxis after an epidural or spinal anesthesia in patients treated with anticoagulants: Table 3.1-6. Also see Perioperative Direct Oral Anticoagulant (DOAC) Management

TablesTop

Table 3.1-6. Timing of procedures in patients treated with antithrombotic drugsa

Agent

Lumbar puncture (with or without introduction of catheter)

Removal of epidural or spinal catheter in patients treated with anticoagulantsb

Starting antithrombotic prophylaxis after spinal or epidural anesthesia

Acetylsalicylic acid

No restrictions

No restrictions

No restrictions

Clopidogrel

≥7 days from discontinuation of the drug

After catheter removal

Ticlopidine

≥14 days from discontinuation of the drug

After catheter removal

Vitamin K antagonistc

4 days from the discontinuation of the drug + normal INR

When INR <1.5

After catheter removal

Unfractionated IV heparin

4 h after discontinuation of IV infusion and normalization of aPTT

4 h after discontinuation of infusion and normalization of aPTT

– >2 h after removal of catheter

– Defer by 12 h in case of bloody puncture (applies to intraoperative use of IV UFH)

SC UFH

4 h after SC injection of prophylactic dose

4 h after SC injection of prophylactic dose

1 h after removal of catheter

SC LMWH

– 10-12 h after standard prophylactic dose

– 24 h after last therapeutic dose and after normalization of anti-Xa activity

– 10-12 h after last dose and 4 h before next dose

– 24 h after last dose (with doses administered every 24 h)

– 2-4 h after removal of catheter

– Defer by 24 h in case of bloody puncture (applies to therapeutic dose)

Fondaparinux

– 24-36 h after standard prophylactic dose (2.5 mg SC every 24 h)

– 48-72 h after standard therapeutic dose (7.5 mg SC every 24 h)

36-42 h after last dose (no data available on safety of fondaparinux in patients with indwelling spinal or epidural catheters; other anticoagulants should be used)

– 6-12 h after removal of catheter in patients receiving prophylactic doses (2.5 mg SC every 24 h)

– 12-24 h after removal of catheter in patients receiving therapeutic doses (7.5 mg SC every 24 h) or in patients at high bleeding risk

Oral factor Xa inhibitord

Hold day of procedure and 2 days prior (>48 h after last dose)

Hold day of procedure and 2 days prior (>48 h after last dose)

6-12 h after removal of catheter in patients starting prophylactic dosesf

≥24 h after removal of catheter in patients resuming therapeutic dosesg

Oral direct thrombin inhibitore

Hold day of procedure and 2 days prior (>48 h after last dose) (hold 4 days if CrCl <50 mL/min)

Hold day of procedure and 2 days prior (>48 h after last dose) (hold 4 days if CrCl <50 mL/min)

6-12 h after removal of catheter in patients starting prophylactic dosesh

≥24 h after removal of catheter in patients resuming therapeutic dosesi

a No high-quality data is available for oral direct factor Xa inhibitors or thrombin inhibitors.

b Applies to patients with normal renal function.

c Acenocoumarol and warfarin.

d Apixaban, edoxaban, and rivaroxaban.

e Dabigatran.

f Apixaban 2.5 mg bid, edoxaban 30 mg once daily, or rivaroxaban 10 mg once daily.

g Apixaban 5 mg bid, edoxaban 60 mg once daily, or rivaroxaban 20 mg once daily.

h Dabigatran 150-220 mg once daily.

i Dabigatran 110-150 mg twice daily.

aPTT, activated partial thromboplastin time; bid, 2 times a day; CrCl, creatinine clearance; INR, international normalized ratio; LMWH, low-molecular-weight heparin; SC, subcutaneous; UFH, unfractionated heparin.

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