ANTICOAGULATION GUIDELINES FOR NEURAXIAL PROCEDURES
ANTICOAGULATION GUIDELINES FOR NEURAXIAL PROCEDURES
ANTICOAGULATION GUIDELINES FOR NEURAXIAL PROCEDURES
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VTEUniversity of Washington Medical Center (UWMC)<strong>ANTICOAGULATION</strong> <strong>GUIDELINES</strong> <strong>FOR</strong> <strong>NEURAXIAL</strong> <strong>PROCEDURES</strong>Guidelines to Prevent Spinal Hematoma following Epidural/Intrathecal/Spinal Procedures andPerineural Hematoma following Peripheral Nerve ProceduresATTENTION! WHEN CAN YOU SAFELY DO <strong>NEURAXIAL</strong>/PERIPHERAL NERVE <strong>PROCEDURES</strong> OR GIVE ANTICOAGULANTS?Neuraxial routes include epidural and intrathecal infusions, implanted intrathecal pumps, and spinal injections.Peripheral routes include all peripheral nerve and plexus infusions. NOTE: Bloody tap/procedure? Anesthesia to call Pain ServiceMEDICATIONPRIOR TO<strong>NEURAXIAL</strong>/NERVEPROCEDUREMinimum time between last dose ofanticoagulant andspinal injection OR neuraxial/nervecatheter placementANTICOAGULANTS <strong>FOR</strong> VTE PROPHYLAXISheparin unfractionated5000 units q8 or q12 hrheparin unfractionated7500 units SQ q8 hr 8 hrsWHILE<strong>NEURAXIAL</strong>/NERVECATHETER IN PLACERestrictions on use ofanticoagulants in patients withneuraxial/nerve catheters in placeMinimum time betweenneuraxial/nerve catheter removalOR spinal/nerve injection and nextanticoagulant doseMay be given; no time restrictions for catheter placement/removal or spinal injectionsDo NOT call Pain ServiceCONTRAINDICATEDwhile catheter in place:may NOT be given unless approvedby Pain Service AttendingAFTER<strong>NEURAXIAL</strong>/NERVEPROCEDURE2 hrsdalteparin (Fragmin)5000 units SQ qdayenoxaparin (Lovenox)40mg SQ qday12 hrs (longer in renal impairment)May be given BUT contact PainService regarding dose timing•Must wait 6-8 hrs after catheterPLACEMENT before giving dose•Must wait 18-24 hours after last dosebefore REMOVING catheter2 hrsenoxaparin (Lovenox)30mg SQ q12 hr or40mg SQ q12 hrfondaparinux (Arixtra)< 2.5mg SQ qday12 hrs (longer in renal impairment)48 hrs (longer in renal impairment)CONTRAINDICATEDwhile catheter in place:may NOT be given unless approvedby Pain Service Attending2 hrsrivaroxaban (Xarelto)10mg po qdayAGENTS USED <strong>FOR</strong> FULL SYSTEMIC <strong>ANTICOAGULATION</strong>dabigatran (Pradaxa) 72 hrs (longer in renal impairment)dalteparin (Fragmin)200 Units/kg SQ qday or100 Units/kg SQ q12 hrdrotrecogin (Xigris)enoxaparin (Lovenox)1.5mg/kg SQ qday or1mg/kg SQ q12h18 hrs (longer in renal impairment)24 hrs (longer in renal impairment)24 hrs (longer in renal impairment)24 hrs (longer in renal impairment)May be given BUT contact PainService regarding dose timing•Must wait 6-8 hrs after catheterPLACEMENT before giving dose•Must wait 18-24 hours after last dosebefore REMOVING catheterCONTRAINDICATEDwhile catheter in place:may NOT be givenunless approved byPain Service Attending6 hrs(per manufacturerrecommendations)2 hoursfondaparinux (Arixtra)5-10mg SQ qdayheparin unfractionatedIV continuous infusion or>5000 Units SQ bid or tidwarfarin (Coumadin)72 hrs (longer in renal impairment)when aPTT
VTEUniversity of Washington Medical Center (UWMC)<strong>ANTICOAGULATION</strong> <strong>GUIDELINES</strong> <strong>FOR</strong> <strong>NEURAXIAL</strong> <strong>PROCEDURES</strong>Guidelines to Prevent Spinal Hematoma following Epidural/Intrathecal/Spinal Procedures andPerineural Hematoma following Peripheral Nerve ProceduresATTENTION! WHEN CAN YOU SAFELY DO <strong>NEURAXIAL</strong>/PERIPHERAL NERVE <strong>PROCEDURES</strong> OR GIVE ANTICOAGULANTS?Neuraxial routes include epidural and intrathecal infusions, implanted intrathecal pumps, and spinal injections.Peripheral routes include all peripheral nerve and plexus infusions. NOTE: Bloody tap/procedure? Anesthesia to call Pain ServiceMEDICATIONDIRECT THROMBIN INHIBITORSargatrobanIV continuous infusionbivalirudin (Angiomax)IV continuous infusionlepirudin (Refludan)IV continuous infusionANTIPLATELET AGENTSAspirin/NSAIDSabciximab (Reopro)clopidogrel (Plavix)eptifibatide (Integrelin)prasugrel (Effient)tirofiban (Aggrastat)THROMBOLYTIC AGENTSalteplase (TPA)2mg dose for catheter clearancealteplase (TPA)full dose for stroke, MI, etcPRIOR TO<strong>NEURAXIAL</strong>/NERVEPROCEDUREMinimum time between last dose ofanticoagulant andspinal injection OR neuraxial/nervecatheter placementwhen DTI assay < 40or aPTT < 40 sec48 hrs7 days10 daysCONTRAINDICATEDCONTRAINDICATEDwhilewhilecathetercatheter inplace:in place:maymayNOTNOTbebegivengivenunlessunlessapprovedapproved bybyPain Pain Service AttendingCONTRAINDICATEDwhile catheter in place:may NOT be givenunless approved byPain Service AttendingCONTRAINDICATEDwhile catheter in place:may NOT be givenunless approved byPain Service Attending2 hoursMay be given; no time restrictions for catheter placement or removalDo NOT call Pain Service8 hrs (longer in renal impairment)7 days8 hrs (longer in renal impairment)WHILE<strong>NEURAXIAL</strong>/NERVECATHETER IN PLACERestrictions on use ofanticoagulants in patients withneuraxial/nerve catheters in placeAFTER<strong>NEURAXIAL</strong>/NERVEPROCEDUREMinimum time betweenneuraxial/nerve catheter removalOR spinal/nerve injection and nextanticoagulant dose2 hoursMay be given; no time restrictions for catheter placement or removal(Maximum dose 4mg/24 hours)10 daysUse with UWMC Nursing Epidural Policy and Procedure (Sheryl Wyant), UWMC Anticoagulation Services www.uwmcacc.org (Ann Wittkowsky), Acute Pain Service (Dermot Fitzgibbon)and on line Clinical Toolkit: depts.washington.edu/medical/clinicalresources (Tom Staiger).Reference: Horlocher TT et al. Regional anesthesia in the patient receiving antithrombotic orthrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (third edition). Reg Anesth Pain Med 2010; 35:64-101.www.vte.eduwww.uwmcacc.org© October 6, 2011page 2 of 2
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