Anticoagulant Treatment and Regional Anesthesia

How to Cite This Chapter: Douketis J, Undas A, Zawilska K. Anticoagulant Treatment and Regional Anesthesia. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.2.34.5. Accessed May 28, 2024.
Last Updated: June 11, 2021
Last Reviewed: June 11, 2021
Chapter 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 1. 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 catheter introduction)

Removal of epidural or spinal catheter in patients treated with anticoagulantsb

Starting antithrombotic prophylaxis after spinal or epidural anesthesia

ASA

No restrictions

No restrictions

No restrictions

Clopidogrel

≥7 days from drug discontinuation (min 5)

After catheter removal

Prasugrel

≥10 days from drug discontinuation (min 7)

≥10 days from drug discontinuation

After catheter removal

Ticagrelor

≥5 days from drug discontinuation (min 3)

After catheter removal

VKAc

4 days from drug discontinuation + normal INR

When INR <1.5

After catheter removal

UFH IV

4 h after discontinuation of IV infusion and aPTT normalization

4 h after discontinuation of infusion and aPTT normalization

– >2 h after catheter removal

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

UFH SC

4 h after SC injection of prophylactic dose

4 h after SC injection of prophylactic dose

1 h after catheter removal

LMWH SC

– 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 catheter removal

– 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 catheter removal in patients receiving prophylactic doses (2.5 mg SC every 24 h)

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

Factor Xa inhibitor (oral)d

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 catheter removal in patients starting prophylactic dosesf

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

Direct thrombin inhibitor (oral)e

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 catheter removal in patients starting prophylactic dosesh

≥24 h after catheter removal 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 bid.

aPTT, activated partial thromboplastin time; ASA, acetylsalicylic acid; bid, 2 times a day; CrCl, creatinine clearance; INR, international normalized ratio; IV, intravenous; LMWH, low-molecular-weight heparin; SC, subcutaneous; UFH, unfractionated heparin; VKA, vitamin K antagonist.

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