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 (8
thedition). CHEST 2008;133:Page 382S
2. Various chapters from The American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9
thedition) 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
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 Unfractionated Heparin 5,000 units q12hrs or q8 hrs
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
Low Molecular Weight Heparin Enoxaparin 30mg SC q12h Enoxaparin 40mg SC q24h Dalteparin 5,000 units SC q24h
Dalteparin 2,500 units SC q24h
Delay needle placement for a minimum of 12 hours4 Pre-operative LMWH is not recommended with neuraxial procedures. 2
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.
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.
4 hours
Fondaparinux 2.5mg Delay needle placement for a minimum of 72 hours 4
Avoid use if an epidural catheter is in place.
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
THERAPEUTIC Dosing
Unfractionated Heparin (IV or SC)
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
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
4 hours
Low Molecular Weight Heparin
Enoxaparin 1mg/kg SC q12h Enoxaparin 1.5mg/kg SC q24h
Dalteparin 100units/kg SC q12h
Dalteparin 200units/kg SC q24h
Delay needle placement for a minimum of 24 hours 4
Contraindicated when an epidural catheter in place. Can start LMWH once catheter is removed.
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
Fondaparinux 5mg, 7.5mg, 10mg
Delay needle placement for a minimum of 72 hours 4
Avoid use if an epidural catheter is in place.
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
Bivalirudin Hold infusion 4-6 hours.
Delay until thrombin time (TT) has normalized to baseline
Avoid use if an epidural catheter is in place.
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
ORAL Agents
Warfarin 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.
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.
Dabigatran 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
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.
4 hours Dabigatran NOT recommended in patients who have a catheter in place.
Rivaroxaban 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
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 rivaroxaban was started and an epidural is in place, consider waiting 18 hours or longer before removing the catheter.
6 hours
Rivaroxaban NOT recommended in patients who have a catheter in place.
Apixaban 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
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
No specific recommendations.
Consider 48 hours Apixaban NOT recommended in patients who have a catheter in place.
Edoxaban Stop edoxaban at least 3 days prior to insertion.
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
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
2 hours after catheter removal.
Edoxaban NOT recommended in patients who have catheter in place.
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
CONTRAINDICATED while catheter in place
Avoid removal during antiplatelet treatment. A minimum of 48 hours between discontinuation of abciximab and catheter removal is recommended.
2 hours
Eptifibatide 8 hours* Avoid removal during antiplatelet
treatment. A minimum of 8 hours between discontinuation of eptifibatide and catheter removal is recommended.
2 hours
Tirofiban 8 hours* Avoid removal during antiplatelet
treatment. A minimum of 8 hours between discontinuation of tirofiban and catheter removal is recommended.
2 hours
ORAL Agents
Aspirin/NSAIDs No significant risk; no contraindications exist Aggrenox
(dipyridamole + aspirin
No significant risk; no contraindications exist
Dipyridamole No significant risk; no contraindications exist
Clopidogrel 7 days
CONTRAINDICATED while catheter in place
Avoid removal during antiplatelet treatment. A minimum of 7 days between discontinuation of clopidogrel and catheter removal is recommended.
2 hours
Prasugrel 7-10 days Avoid removal during antiplatelet
treatment. A minimum of 7-10 days between discontinuation of prasugrel and catheter removal is recommended.
6 hours
Ticagrelor 5 days Avoid removal during antiplatelet
treatment. A minimum of 5 days between discontinuation of ticagrelor and catheter removal is recommended.
6 hours
Cilostazol 42 hours Avoid removal during antiplatelet
treatment. A minimum of 42 hours between discontinuation of cilostazol and catheter removal is recommended.
5 hours
Ticlopidine 10 days Avoid removal during antiplatelet
treatment. A minimum of 10 days between discontinuation of ticlopidine and catheter removal is recommended.
2 hours
Vorapaxar Minimum hold period prior to catheter placement has not been
established
Avoid removal during antiplatelet treatment. Minimum hold period prior to catheter placement has not
been established
Minimum amount of elapsed time between catheter insertion or removal has not been established
Anagrelide 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.
Minimum amount of elapsed time between catheter insertion or removal has not been established
Pentosan Minimum hold period prior to catheter
A minimum amount of time to safely remove a catheter has not been
Minimum amount of elapsed time between catheter
