ANTICOAGULATION GUIDELINES FOR NEURAXIAL …

1 PRIOR TO NEURAXIAL /NERVE PROCEDURE Minimum time between last dose of antithrombotic agent AND NEURAXIAL injection or NEURAXIAL /nerve catheter placementWHILE NEURAXIAL /NERVE CATHETER IN PLACER estrictions on use of antithrombotic agents while NEURAXIAL /nerve catheters are in place and prior to their removalAFTER NEURAXIAL /NERVE PROCEDUREM inimum time between NEURAXIAL injection or NEURAXIAL /nerve catheter removal AND next dose of antithrombotic agentHeparin 5000 units SQ q8h or q12h4-6 hours verify normal aPTT May be given; preferred over alternatives1 hourHeparin 7500 units SQ q8h or q12h 12 hoursverify normal aPTTMay be given; preferred over alternatives1 hourHeparin IV infusion4-6 hours verify normal aPTT May be given; preferred over alternatives1 hourDalteparin (Fragmin)CONTRAINDICATEDE noxaparin (Lovenox) 40 mg SQ daily 12 hoursMay be maintained with once daily dosing, without administration of any other antihemostatic drugs4 hoursEnoxaparin (Lovenox) 30 mg SQ q12h 12 hours4 hoursEnoxaparin (Lovenox) mg/kg SQ daily or 1 mg/kg SQ q12h 24 hours4 hoursFondaparinux (Arixtra) 36-42 hoursCONTRAINDICATED6 hoursApixaban (Eliquis) mg BID - 5 mg BID3 daysCONTRAINDICATED6 hoursANTICOAGULATION GUIDELINES FOR NEURAXIAL PROCEDURES GUIDELINES to Minimize Risk Spinal Hematoma with NEURAXIAL Procedures**ANTICOAGULANTS, INJECTABLEANTICOAGULANTS, ORALCONTRAINDICATED Risk of spinal/epidural hematomas Rivaroxaban (Xarelto)15-20 mg daily3 daysCONTRAINDICATED6 hoursBetrixaban (Bevyxxa) 80 mg daily3 daysCONTRAINDICATED5 hoursEdoxaban (Savaysa) 30-60 mg daily3 daysCONTRAINDICATED6 hoursDabigatran (Pradaxa)

2 75-150 mg BID CrCl < 30 mL/min: avoid NACrCl 30-49 mL/min: 5 daysCrCl 50-79 mL/min: 4 daysCrCl 80 mL/min: 3 daysRenal fxn unknown: 5 daysCONTRAINDICATED6 hoursWarfarin (Coumadin) 4-5 days verify normal INR check INR dailyremove when INR < IV infusionBivalirudin (Angiomax) IV infusionAspirin May continue dosageMay continue dosageNSAIDsMay continue dosageMay continue dosageAspirin/dipyridamole (Aggrenox) 24 hoursCONTRAINDICATED6 hoursCangrelor (Kengreal) IV infusion3 hoursCONTRAINDICATED 8 hours Clopidogrel (Plavix)5-7 days CONTRAINDICATED Without LD: immediateWith LD: 6 hours ANTIPLATELET AGENTS Avoid NEURAXIAL techniquesAvoid NEURAXIAL techniquesAvoid NEURAXIAL techniques if early postoperative use of other anti-hemostatic drugs is anticipatedDIRECT THROMBIN INHIBITORS, INJECTABLEP rasugrel (Effient) 7-10 daysCONTRAINDICATED Without LD: immediateWith LD: 6 hours Ticagrelor (Brilinta) 5-7 days CONTRAINDICATED Without LD: immediateWith LD: 6 hours Abciximab (Reopro) IV infusion24-48 hours CONTRAINDICATEDT irofiban (Aggrastat) IV infusion4-8 hoursCONTRAINDICATEDE ptifibatide (Integrelin) IV infusion4-8 hoursCONTRAINDICATEDA lteplase (TPA) 1 mg dose for catheter clearanceCONTRAINDICATEDA lteplase (TPA) Full dose for stroke, MI, etc CONTRAINDICATED** GUIDELINES do not address risks with multiple therapies or comorbidities that interfere with coagulation.

3 Consult appropriate expert(s) as needed. Last revised 3/26/19 THROMBOLYTIC TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based GUIDELINES (Fourth Edition). Reg Anesth Pain Med 2018; 43 W, Vandermuelen E, Van Aken H, et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 27:999. Contraindicated for 4 weeks after surgery; monitor neurologic status if given after NEURAXIAL technique