Neuraxial procedures and anticoagulation

This is a review of the guidelines for using anticoagulant medications around neuraxial procedures, which include epidurals and spinal anesthesia.
This information is adapted from the ARSA 2018 fourth generation guidelines for antithrombotic or thrombolytic therapy, Wikipedia, and TrueLearn. Images are adapted from Wikimedia Commons: By Southwest (talk) - Own work, CC BY-SA 4.0, commons.wikimedia.org/w/index...
ADDITIONAL TAGS:
According to ARSA 2018 fourth generation guidelines for antithrombotic or thrombolytic therapy, which can cause epidural hematoma, resulting in:
progression of sensory or motor blockade
bowel and bladder dysfunction
spinal cord ischemia
Notes:
If patient got LMWH (Lovenox) for over 4 days, check platelets before neuraxial procedure / removing catheter
Normal coagulation status = normal coag labs (PT/INR, PTT)
Warfarin: stop it 5 days before neuraxial procedure and ensure INR is normalized before neuraxial placement
Medication
HOLD before
neuraxial procedure
RESTART after
neuraxial procedure
HOLD before
neuraxial cath removal
RESTART after
neuraxial catheter removal
Low-dose SQ heparin (5000 units BID or TID)
4-6 hr OR normal coagulation status
Immediately
4-6 hr
Immediately
High-dose SQ heparin (7500-10,000 units BID)
12 hr AND normal coagulation status
Avoid if catheter
in place
Avoid if catheter in place
Immediately
Therapeutic SQ heparin (over 20,000 units per day)
24 hr AND normal coagulation status
Avoid if catheter
in place
Avoid if catheter in place
Immediately
IV heparin
4-6 hr AND normal coagulation status
1 hr
4-6 hr AND normal coagulation status
1 hr
Prophylactic LMWH
(daily dosing)
12 hr
12 hr
12 hr
4 hr AND no earlier than 12 hr after catheter placement
Prophylactic LMWH
(BID dosing)
12 hr
Avoid if catheter in place 12 hr after single-shot
Avoid if catheter in place
4 hr AND no earlier than 12 hr after cath placement
Therapeutic LMWH
24 hr
Avoid if cath in place 24-72 hr after single-shot
Avoid if catheter in place
4 hr AND no earlier than 24 hr after catheter placement

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