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    Stop Anticoagulation Neuraxial Anesthesia

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    Gihan Nakhleh
    This document provides guidelines for managing antithrombotic therapy for neuraxial and peripheral nerve procedures to prevent hematoma formation. It outlines restrictions on use of various anticoagulants and antiplatelet medications prior to, during, and after such procedures based on medication, dose, renal function and coagulation assay results. Minimum time intervals are specified between last doses of medications and procedures or catheter removal. Direct thrombin inhibitors and several anticoagulants used for full systemic anticoagulation are contraindicated while neuraxial/peripheral nerve catheters are in place without approval from pain or anesthesia services.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Stop Anticoagulation Neuraxial Anesthesia

    Uploaded by

    Gihan Nakhleh
    984 views3 pages
    This document provides guidelines for managing antithrombotic therapy for neuraxial and peripheral nerve procedures to prevent hematoma formation. It outlines restrictions on use of various anticoagulants and antiplatelet medications prior to, during, and after such procedures based on medication, dose, renal function and coagulation assay results. Minimum time intervals are specified between last doses of medications and procedures or catheter removal. Direct thrombin inhibitors and several anticoagulants used for full systemic anticoagulation are contraindicated while neuraxial/peripheral nerve catheters are in place without approval from pain or anesthesia services.

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    How long to stop anticoagulation to do neuraxial anesthesia

    Original Title

    Stop Anticoagulation neuraxial anesthesia

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    This document provides guidelines for managing antithrombotic therapy for neuraxial and peripheral nerve procedures to prevent hematoma formation. It outlines restrictions on use of various anticoagulants and antiplatelet medications prior to, during, and after such procedures based on medication, dose, renal function and coagulation assay results. Minimum time intervals are specified between last doses of medications and procedures or catheter removal. Direct thrombin inhibitors and several anticoagulants used for full systemic anticoagulation are contraindicated while neuraxial/peripheral nerve catheters are in place without approval from pain or anesthesia services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    984 views3 pages

    Stop Anticoagulation Neuraxial Anesthesia

    Uploaded by

    Gihan Nakhleh
    This document provides guidelines for managing antithrombotic therapy for neuraxial and peripheral nerve procedures to prevent hematoma formation. It outlines restrictions on use of various anticoagulants and antiplatelet medications prior to, during, and after such procedures based on medication, dose, renal function and coagulation assay results. Minimum time intervals are specified between last doses of medications and procedures or catheter removal. Direct thrombin inhibitors and several anticoagulants used for full systemic anticoagulation are contraindicated while neuraxial/peripheral nerve catheters are in place without approval from pain or anesthesia services.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3
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    The document outlines guidelines for administering various anticoagulants and antiplatelet agents before, during, and after neuraxial or peripheral nerve procedures based on the medication, dosage, and creatinine clearance.

    The document provides minimum time intervals that must elapse between the last dose of various anticoagulants and the neuraxial or nerve procedure, ranging from 4 to 48 hours depending on the specific medication, dose, and creatinine clearance.

    For most anticoagulants, administration is either contraindicated or requires approval from pain services or anesthesia while a catheter is in place. Some low dose heparin may be given with restrictions.

    MANAGEMENT OF ANTITHROMBOTIC THERAPY

    FOR NEURAXIAL AND PERIPHERAL NERVE PROCEDURES1


    Guidelines to Prevent Neuraxial Hematoma after Epidural/Intrathecal/Spinal Injections and
    Perineural Hematoma following Peripheral Nerve procedures, excluding Chronic Pain Procedures ONLY
    These guidelines are not intended to supersede clinical judgement.

    ATTENTION! WHEN CAN YOU SAFELY DO NEURAXIAL/PERIPHERAL NERVE PROCEDURES OR GIVE ANTITHROMBOTIC AGENTS?
    NOTE: For concerns related to bleeding or traumatic procedures, contact Pain Service.

    PRECAUTIONS:
    Do NOT give MULTIPLE anticoagulants, including antiplatelet agents, concurrently in patients undergoing Neuraxial/Nerve Procedures.
    Delay restarting anticoagulants for 24 hours after traumatic needle placement.

    A. PRIOR TO B. WHILE C. AFTER


    NEURAXIAL/NERVE NEURAXIAL/NERVE NEURAXIAL/NERVE
    PROCEDURE CATHETER IN PLACE PROCEDURE
    Minimum time between last Restrictions on use of antithrombotic Minimum time between
    MEDICATION dose of antithrombotic agent agents while neuraxial/nerve catheters are neuraxial injection or
    AND neuraxial injection or in place and prior to their removal neuraxial/nerve catheter
    neuraxial/nerve catheter removal AND next dose of
    placement antithrombotic agent
    ANTICOAGULANTS FOR VTE PROPHYLAXIS

    heparin unfractionated May be given; no time restrictions for neuraxial injection or neuraxial/nerve catheter placement
    5000 units SQ Q8H or Q12H Does not require Pain Service approval.

    CONTRAINDICATED
    while catheter in place.
    * heparin unfractionated
    12 hours May NOT be given unless approve by 4 hours
    7500 units SQ Q8H
    Pain Service or Obstetric Anesthesia
    Attending

    * dalteparin (Fragmin)
    5000 units SQ QDay May be given BUT:
    •Must wait 8 hours after catheter
    12 hours – CrCl ≥ 30 ml/min
    PLACEMENT before giving dose 4 hours
    24 hours – CrCl < 30 ml/min
    •Must wait 12 hours after last dose before
    * enoxaparin (Lovenox) REMOVING catheter
    40mg SQ QDay

    * enoxaparin (Lovenox)
    12 hours – CrCl ≥ 30 ml/min
    30mg SQ Q12H or CONTRAINDICATED 4 hours
    24 hours – CrCl < 30 ml/min
    40mg SQ Q12H while catheter in place.
    May NOT be given unless approve by
    Pain Service or Obstetric Anesthesia
    fondaparinux (Arixtra) 48 hours – CrCl ≥ 30 ml/min
    Attending 6 hours
    2.5mg SQ QDay CrCl < 30 ml/min: Call Hematology

    48 hours – CrCl ≥ 50 ml/min


    apixaban (Eliquis)
    72 hours – CrCl 30-50 ml/min
    2.5mg bid
    CrCl < 30 ml/min: Call Hematology May be given BUT:
    •Must wait 8 hours after catheter
    48 hours – CrCl ≥ 50 ml/min
    rivaroxaban (Xarelto) PLACEMENT before giving dose
    72 hours – CrCl 30-50 ml/min 6 hours
    10mg po QDay •Must wait 12 hours after last dose before
    CrCl < 30 ml/min: Call Hematology
    REMOVING catheter
    72 hours – CrCl ≥ 30 ml/min
    betrixaban (Bevyxxa)
    96 hours – CrCl 15-30 ml/min
    80mg QDay
    CrCl < 15 ml/min: Call Hematology

    * for use of these specific agents/doses with select superficial, lower extremity PNCs at Harborview Medical Center only, see internal
    recommendations available on HMC Integrated Pain Care Program website https://hmc.uwmedicine.org/BU/pain/Pages/default.aspx

    JUNE 2018 Page 1


    MANAGEMENT OF ANTITHROMBOTIC THERAPY
    FOR NEURAXIAL AND PERIPHERAL NERVE PROCEDURES1
    Guidelines to Prevent Neuraxial Hematoma after Epidural/Intrathecal/Spinal Injections and
    Perineural Hematoma following Peripheral Nerve procedures, excluding Chronic Pain Procedures ONLY
    These guidelines are not intended to supersede clinical judgement.

    AGENTS USED FOR FULL SYSTEMIC ANTICOAGULATION

    48 hours – CrCl ≥ 50 ml/min


    apixaban (Eliquis)
    72 hours – CrCl 30-50 ml/min
    2.5mg bid – 10mg bid
    CrCl < 30 ml/min: Call Hematology

    rivaroxaban (Xarelto) 48 hours – CrCl >50 ml/min


    15-20mg po qday or 15mg bid CrCl < 50 ml/min: Call Hematology

    edoxaban (Savaysa) 6 hours


    48 hours – CrCl ≥ 50 ml/min
    30-60mg QDay CrCl < 50 mL/min: Call Hematology

    72 hours – CrCl 50 ml/min


    dabigatran (Pradaxa)
    120 hours – CrCl 30-50 ml/min
    75mg bid – 150mg bid
    CrCl < 30 ml/min: Call Hematology

    fondaparinux (Arixtra) 72 hours – CrCl ≥ 30 ml/min


    CONTRAINDICATED
    5-10mg SQ QDay CrCl < 30 ml/min: Call Hematology
    while catheter in place.
    May NOT be given unless approve by
    dalteparin (Fragmin) Pain Service or Obstetric Anesthesia
    24 hours – CrCl ≥ 30 ml/min
    200 Units/kg SQ QDay or Attending
    48 hours – CrCl < 30 ml/min
    100 Units/kg SQ Q12H

    enoxaparin (Lovenox)
    24 hours – CrCl ≥ 30 ml/min
    1.0 - 1.5mg/kg SQ QDay or
    48 hours – CrCl < 30 ml/min
    1mg/kg SQ Q12H

    heparin unfractionated when aPTT normal or anti-Xa


    IV infusion activity undetectable 4 hours

    heparin unfractionated when aPTT normal or anti-Xa


    full dose SQ activity undetectable

    warfarin (Coumadin) when INR ≤ 1.5

    DIRECT THROMBIN INHIBITORS, INJECTABLE


    when DTI assay < 40
    or aPTT < 40 sec
    argatroban
    IV continuous infusion CONTRAINDICATED
    while catheter in place.
    when DTI assay < 40 May NOT be given unless approve by 4 hours
    or aPTT < 40 sec Pain Service or Obstetric Anesthesia
    bivalirudin (Angiomax) Attending
    IV continuous infusion

    JUNE 2018 Page 2


    MANAGEMENT OF ANTITHROMBOTIC THERAPY
    FOR NEURAXIAL AND PERIPHERAL NERVE PROCEDURES1
    Guidelines to Prevent Neuraxial Hematoma after Epidural/Intrathecal/Spinal Injections and
    Perineural Hematoma following Peripheral Nerve procedures, excluding Chronic Pain Procedures ONLY
    These guidelines are not intended to supersede clinical judgement.

    ANTIPLATELET AGENTS pages 285-286


    aspirin or NSAIDS May be given; no time restrictions for neuraxial injection or neuraxial/nerve catheter placement
    Does not require Pain Service approval

    abciximab (Reopro)
    48 hours
    IV continuous infusion

    aspirin/dipyridamole
    24 hours
    (Aggrenox)

    cangrelor (Kengreal)
    3 hours
    IV continuous infusion

    clopidogrel (Plavix) CONTRAINDICATED


    while catheter in place.
    6 hours
    May NOT be given unless approved by
    prasugrel (Effient) 7 days Pain Service Attending

    ticagrelor (Brilinta)

    tirofiban (Aggrastat)
    IV continuous infusion
    8 hours– CrCl > 50 ml/min
    CrCl < 50 Call Hematology
    eptifibatide (Integrelin)
    IV continuous infusion

    THROMBOLYTIC AGENTS
    alteplase (TPA) May be given; no time restrictions for neuraxial injection or neuraxial/nerve catheter placement
    1mg dose for catheter Does not require Pain Service approval
    clearance (Maximum dose 4mg/24 hours)
    alteplase (TPA) CONTRAINDICATED
    full dose for stroke, MI, etc while catheter in place.
    48 hours 10 days
    May NOT be given unless approved by
    Pain Service Attending
    References
    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 (4th ed).
    Reg Anesth Pain Med 2018; 43(3):263-309
    Burnett AE, et al. Guidance for the practical management of the direct oral anticoagulants (DOACs) in VTE treatment. J Thromb Thrombolysis (2016) 41:206–232. DOI 10.1007/s11239-015-1310-7.

    Each recommendation was reviewed by members of anesthesiology, hematology and pharmacy to determine the class (strength of
    recommendation) and level (quality of the evidence) using the 2018 American Society of Regional Anesthesia and Pain Medicine
    (ASRA) Guidelines. These recommendations were approved by the UW Medicine Thrombosis and Anticoagulation Safety Committee.
    In any case of discrepancy from the ASRA 2018 Regional and Antithrombotic Guidelines, a final decision was reached after
    consideration of medication pharmacokinetics, procedure and thrombosis risk and clinical experience. These guidelines are not
    intended to set out a legal standard of care and do not replace medical care or the judgment of the responsible medical professional
    considering all the circumstances presented by an individual patient. This consensus statement is not intended to ensure a
    successful patient outcome in every situation and is not a guarantee of any specific outcome.

    For questions/comments:
    David Garcia, MD (Hematology): [email protected]
    Laurent Bollag, MD (Anesthesiology and Pain Medicine): [email protected]
    Susan Rayner, PharmD (Cardiology & Oncology Critical Care Pharmacist): [email protected]
    Mina Lee, PharmD (Pain Pharmacist): [email protected]

    JUNE 2018 Page 3

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