Guidelines for Neuraxial Anesthesia and Anticoagulation
NOTE: The decision to perform a neuraxial block on a patient receiving perioperative (anticoagulation) must be made on an
individual basis by weighing the risk of spinal hematoma with the benefits of regional anesthesia for a particular patient.
Prior to Catheter With Catheter in Prior to Catheter After Catheter
Medication Placement Place Removal Removal Additional Info Half Life
(Minimum time between the last dose (When to restart (Time between the last dose ( When to restart
of anticoagulant and initial catheter anticoagulation therapy of anticoagulant and catheter anticoagulation therapy once
placement) once the catheter has removal) catheter has been removed)
been placed)
Heparin
Wait until PTT < 40
IV Heparin
Usual hold time 4 hours Avoid While Catheter is in Perform neuro check 12
hours after cath
SC Heparin Wait until PTT < 40 Place removal
(>5000 units) Usual hold time 12 hours
2 hours 1-2 hrs
SC Heparin TID
( 5000 units) Hold AM dose and check Hold AM dose Use of compression
PTT prior to placement No restrictions check PTT prn
device is also
recommended
SC Heparin BID
( 5000 units)
Warfarin
May receive first
Avoid While dose 24 hours Reversal Vitamin K
Warfarin When INR <1.4 prior to cath or FFP. Perform neuro 20-60
(Coumadin) Usual hold time 4-5 days Catheter is in removal but INR
2 hours check 24 hours after hrs
Place must be < 1.5 cath removal
prior to removal
Developed by Anticoagulation Task Force and Anesthesia Development Team. P&T Approved February 2014. Last update July 2015 Page 1
NOTE: The decision to perform a neuraxial block on a patient receiving perioperative (anticoagulation) must be made on an
individual basis by weighing the risk of spinal hematoma with the benefits of regional anesthesia for a particular patient.
Prior to Catheter With Catheter in Prior to Catheter After Catheter
Medication Placement Place Removal Removal Additional Info Half
(Minimum time between the (When to restart (Time between the last ( When to restart Life
last dose of anticoagulant anticoagulation therapy dose of anticoagulant and anticoagulation therapy
and initial catheter once the catheter has catheter removal) once catheter has been
placement) been placed) removed)
LMWH (Low Molecular Weight Heparins)
Therapeutic Dosing:
Enoxaparin (Lovenox):
1mg/kg SC bid OR
1.5mg/kg daily
Dalteparin: 24 hours Hold time may be
120 units/kg BID OR Avoid While Catheter is in 4 hours
longer in patients with 4-7
200 units/kg daily Place renal impairment hrs
Tinzaparin: (CrCl < 30ml/min)
175 units/kg daily
Prophylactic Dosing: At least 12 hours,
Enoxaparin (Lovenox): 24 hours is
30 mg bid SQ, 40 mg SQ daily recommended
Factor X-a Inhibitors
Consider longer hold
time in patients with
renal impairment 17-21
Fondaparinux (Arixtra) 72 hours 12 hours (CrCl <50-30 mL/min) hrs
Contraindicated in
CrCl < 30 mL/min
Avoid While Catheter is in
Rivaroxaban (Xarelto) 6 hours 5-9
24 hours Place (24 hours for
traumatic punctures) Longer hold times in hrs
patients with renal
6 hours impairment 6-12
Apixaban (Eliquis) 48 hours (24 hours for
traumatic punctures)
hrs
Developed by Anticoagulation Task Force and Anesthesia Development Team. P&T Approved February 2014. Last update July 2015 Page 2
NOTE: The decision to perform a neuraxial block on a patient receiving perioperative (anticoagulation) must be made on an
individual basis by weighing the risk of spinal hematoma with the benefits of regional anesthesia for a particular patient.
Prior to Catheter With Catheter in Prior to Catheter After Catheter
Medication Placement Place Removal Removal Additional Info Half Life
(Minimum time between (When to restart (Time between the last dose of ( When to restart
the last dose of anticoagulation therapy once anticoagulant and catheter anticoagulation therapy
anticoagulant and initial the catheter has been placed) removal) once catheter has been
catheter placement) removed)
Direct Thrombin Inhibitors
Half-life in hepatic 40-50
Argatroban impairment ~ 181 min min
Bivalirudin Wait until Half- life with CrCl 10-29
mL/min ~ 57 min
25 min
(Angiomax) aPTT < 40 2 hours
Lepirudin
Avoid While Catheter is in Place
Half- life with CrCl <15
mL/min up to 2 days
1-3 hrs
(Refludan)
Dabigatran 6 hours Longer hold times in
8-17
5 days (24 hours for patients with renal
(Pradaxa) traumatic punctures) impairment Hrs
Anti-Platelet Agents* - See footnote on page 4 regarding risk of thrombosis if discontinued following stent placement
Aspirin No restrictions
Clopidogrel
7-10 days 2 hours
(Plavix)
Consider extending
Cilostazol time prior to cath 11-13
42 hours 5 hours
(Pletal) placement in patients hrs
with renal impairment
Dipyridamole/ASA
24 hours Avoid While Catheter is in Place 2 hours
(Aggrenox)
Prasugrel
7-10 days 6 hours
(Effient)
Ticagrelor
5-7 days 6 hours
(Brilinta)
Ticlodipine
10-14 days 2 hours
(Ticlid)
Developed by Anticoagulation Task Force and Anesthesia Development Team. P&T Approved February 2014. Last update July 2015 Page 3
NOTE: The decision to perform a neuraxial block on a patient receiving perioperative (anticoagulation) must be made on an
individual basis by weighing the risk of spinal hematoma with the benefits of regional anesthesia for a particular patient.
Prior to Catheter With Catheter in Prior to Catheter After Catheter
Medication Placement Place Removal Removal Additional Info Half
(Minimum time between the last (When to restart (Time between the last dose ( When to restart Life
dose of anticoagulant and initial anticoagulation therapy once of anticoagulant and catheter anticoagulation therapy
catheter placement) the catheter has been placed) removal) once catheter has been
removed)
Fibrinolytics
18-83
Streptokinase
min
26-46
Alteplase
min
10 days Avoid While Catheter is in Place 10 days
115
Tenecteplase
min
13-16
Reteplase
min
Glycoprotein IIb/IIIa inihibitors
Abciximab
48 hours
(Reopro)
Eptifibatide
8 hours Avoid While Catheter is in Place 2 hours
(Integrillin)
Tirofiban
8 hours
(Aggrastat)
*Perioperative antiplatelet management for patient with coronary stents (Please consult cardiology for patient on DAPT for stent <12 months):
Patients with recent coronary stent placement who require surgery present a complex treatment dilemma. These patients are typically on dual anti-platelet therapy (DAPT) -
aspirin plus a P2Y12 platelet inhibitor (clopidogrel/Plavix, prasugrel/Effient, or ticagrelor/Brilinta). Prematurely discontinuing dual anti-platelet therapy after stent
implantation can result in sub-acute stent thrombosis, which is associated with a high incidence of transmural myocardial infarction and death. Surgery creates an
inflammatory pro-thrombotic state, which greatly increases the risk of thrombosis in stents that have not completely re-endothelialized. The risk of late stent thrombosis is
particularly elevated in patients in whom aspirin and the P2Y12 platelet inhibitor are both stopped and then surgery is performed. Please see Intermountain guidelines for
perioperative antiplatelet management for patients with coronary stents for detailed information.
Developed by Anticoagulation Task Force and Anesthesia Development Team. P&T Approved February 2014. Last update July 2015 Page 4
