Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy
Publication Date: April 1, 2018
Last Updated: March 14, 2022
Recommendations
1.0 Administration of Thromboprophylaxis
1.1 For each of the antithrombotic agents, we recommend that clinicians follow the FDA-approved dosing and ACCP management guidelines. (1A)
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2.0 Anesthetic Management of the Patient Receiving Thrombolytic Therapy
Patients receiving fibrinolytic/thrombolytic medications are at risk of serious hemorrhagic events, particularly those who have undergone an invasive procedure. Recommendations are based on the profound effect on hemostasis, the use of concomitant heparin and/or antiplatelet agents (which further increase the risk of bleeding), and the potential for spontaneous neuraxial bleeding with these medications.
2.1 In patients scheduled to receive thrombolytic therapy, we recommend that the patient be queried and medical record reviewed for a recent history of lumbar puncture, spinal or epidural anesthesia, or ESI to allow appropriate monitoring. Guidelines detailing original contraindications to thrombolytic drugs suggest avoidance of these drugs for 10 days following puncture of noncompressible vessels. (1A)
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2.2 In patients who have received fibrinolytic and thrombolytic drugs, we recommend against performance of spinal or epidural anesthetics except in highly unusual circumstances. (1A)
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2.3 Data are not available to clearly outline the length of time neuraxial puncture should be avoided after discontinuation of these drugs. However, a 48-hour time interval and documentation of normalization of clotting studies (including fibrinogen) are suggested. (2C)
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2.4 In those patients who have received neuraxial blocks at or near the time of fibrinolytic and thrombolytic therapy, we recommend that neurological monitoring should be continued for an appropriate interval. It may be that the interval of monitoring should not be more than 2 hours between neurologic checks. If neuraxial blocks have been combined with fibrinolytic and thrombolytic therapy and ongoing epidural catheter infusion, we recommend the infusion should be limited to drugs minimizing sensory and motor block to facilitate assessment of neurologic function. (1C)
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2.5 There is no definitive recommendation for removal of neuraxial catheters in patients who unexpectedly receive fibrinolytic and thrombolytic therapy during a neuraxial catheter infusion. We suggest the measurement of fibrinogen level (one of the last clotting factors to recover) to evaluate the presence of residual thrombolytic effect and appropriate timing of catheter removal. (2C)
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3.0 Anesthetic Management of the Patient Receiving Unfractionated Heparin
Anesthetic management of the heparinized patient was established more than 2 decades ago. Initial recommendations have been supported by in-depth reviews of case series, case reports of spinal hematoma, and the ASA Closed Claims Project.
3.1 We recommend daily review of the patient's medical record to determine the concurrent use of medications that affect other components of the clotting mechanisms. These medications include antiplatelet medications, LMWH, and oral anticoagulants. (1B)
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3.2 Since heparin-induced thrombocytopenia may occur during heparin administration, we recommend that patients receiving IV or SC UFH for more than 4 days have a platelet count assessed prior to neuraxial block or catheter removal. (1C)
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3.3 Intravenous heparin
3.3.1 Discontinue heparin infusion 4 to 6 hours and verify normal coagulation status prior to neuraxial blockade. (1A)
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3.3.2 Avoid neuraxial techniques in patients with other coagulopathies. (1A)
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3.3.3 Delay heparin administration for 1 hour after needle placement. (1A)
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3.3.4 Remove indwelling neuraxial catheters 4 to 6 hours after the last heparin dose (and after assessment of the patient's coagulation status); reheparinize 1 hour after catheter removal. (1A)
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3.3.5 Monitor the patient postoperatively to provide early detection of motor blockade and consider use of minimal concentration of local anesthetics to enhance the early detection of a spinal hematoma. (1A)
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3.3.6 Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case are warranted. (1A)
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3.3.6 Currently, insufficient data and experience are available to determine if the risk of neuraxial hematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. We suggest postoperative monitoring of neurologic function and selection of neuraxial solutions that minimize sensory and motor block to facilitate detection of new/progressive neurodeficits. (2C)
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3.4 Subcutaneous heparin
3.4.1 Preoperative low-dose UFH for thromboprophylaxis. We suggest, in patients receiving SC low-dose UFH with dosing regimens of 5000 U BID or TID, neuraxial block occur 4 to 6 hours after heparin administration, or coagulation status be assessed. (2C)
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3.4.2 Preoperative “higher-dose” UFH for thromboprophylaxis (eg, individual heparin dose of 7500–10,000 U BID or a daily dose of ≤20,000 U). We suggest neuraxial block occur 12 hours after SC heparin administration and assessment of coagulation status. (2C)
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3.4.3 Preoperative therapeutic UFH (eg, individual dose >10,000 U SC per dose or >20,000-U total daily dose). We suggest neuraxial block occur 24 hours after SC heparin administration and assessment of coagulation status. (2C)
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3.4.4 Postoperative low-dose UFH. There is no contraindication to maintaining neuraxial catheters in the presence of low-dose UFH. We suggest catheter removal occur 4 to 6 hours after heparin administration. Subsequent heparin administration may occur 1 hour after catheter removal. (2C)
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3.4.5 Postoperative “higher-dose” UFH. The safety of indwelling neuraxial catheters in patients receiving doses greater than 5000 U or greater than 15,000 U of UFH daily has not been established. We suggest that the risk and benefits be assessed on an individual basis and that techniques to facilitate detection of new/progressive neurodeficits (eg, enhanced neurologic monitoring occur and neuraxial solutions to minimize sensory and motor block) be applied. (2C)
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4.0 Anesthetic Management of the Patient Receiving LMWH
North American recommendations have drawn on the extensive European experience in the development of practice guidelines for the management of patients undergoing spinal and epidural blocks while receiving perioperative LMWH. Previous consensus recommendations have appeared to decrease the risk. Concern remains for higher-dose applications, where sustained therapeutic levels of anticoagulation are present, as well as early postprocedural dosing.
4.1 The anti–factor Xa level is not predictive of the risk of bleeding, although it may be useful in monitoring efficacy of therapy with therapeutic (high dose) regimens. We recommend against the routine use of monitoring of the anti–factor Xa level. An acceptable level of residual anti–factor Xa level for performance of neuraxial block remains undetermined. (1A)
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4.2 Antiplatelet or oral anticoagulant medications administered in combination with LMWH increase the risk of spinal hematoma. Education of the entire patient care team is necessary to avoid potentiation of the anticoagulant effects. We recommend against concomitant administration of medications affecting hemostasis, such as antiplatelet drugs, standard heparin, or dextran, regardless of LMWH dosing regimen when there is an indwelling neuraxial catheter. (1A)
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4.3 Since heparin-induced thrombocytopenia (HIT) may occur during LMWH administration, we recommend that patients receiving LMWH for greater than 4 days have a platelet count assessed prior to neuraxial block or catheter removal. (1C)
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4.4 The presence of blood during needle and catheter placement does not necessitate postponement of surgery. We suggest that initiation of LMWH therapy in this setting should be delayed for 24 hours postoperatively and that this consideration be discussed with the surgeon. (2C)
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4.5 Preoperative LMWH
4.5.1 We recommend that needle placement should occur at least 12 hours after a prophylactic LMWH dose. (1C)
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4.5.2 In patients administered a dose of LMWH 2 hours preoperatively (general surgery patients), we recommend against neuraxial techniques because needle placement would occur close to peak anticoagulant activity. (1A)
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4.5.3 In patients receiving higher (therapeutic) doses of LMWH, such as enoxaparin 1 mg/kg every 12 hours, enoxaparin 1.5 mg/kg daily, dalteparin 120 U/kg every 12 hours, dalteparin 200 U/kg daily, or tinzaparin 175 U/kg daily, we recommend delay of at least 24 hours prior to needle/catheter placement (grade 1C). Consider checking anti–factor Xa activity level, particularly in elderly patients and patients with renal insufficiency. An acceptable level of residual anti–factor Xa activity to proceed with neuraxial block remains undetermined. (2C)
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4.6 Postoperative LMWH
4.6.1 Twice-daily prophylactic dosing. This dosage regimen is associated with an increased risk of spinal hematoma. We recommend the first dose of LMWH should be administered the following day and no earlier than 12 hours after needle/catheter placement, regardless of anesthetic technique, and only in the presence of adequate (surgical) hemostasis. Indwelling catheters should be removed prior to initiation of LMWH thromboprophylaxis. Administration of LMWH should be delayed for 4 hours after catheter removal. (1C)
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4.6.2 Single daily prophylactic dosing. We recommend the first postoperative LMWH dose should be administered at least 12 hours after needle/catheter placement. The second postoperative dose should occur no sooner than 24 hours after the first dose. Indwelling neuraxial catheters do not represent increased risk and may be maintained. However, no additional hemostasis altering medications should be administered because of the additive effects. The catheter should be removed 12 hours after the last dose of LMWH. Subsequent LMWH dosing should occur at least 4 hours after catheter removal. (1C)
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4.6.3 Single or BID therapeutic dosing. Therapeutic-dose LMWH may be resumed 24 hours after non–high-bleedingrisk surgery and 48 to 72 hours after high-bleeding-risk surgery. We recommend that indwelling neuraxial catheters be removed 4 hours prior to the first postoperative dose and at least 24 hours after needle/catheter placement, whichever is greater. (1C)
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5.0 Anesthetic Management of the Patient Receiving Fondaparinux
5.1 Based on the sustained and irreversible antithrombotic effect, early postoperative dosing, and the spinal hematoma reported during initial clinical trials, we recommend that until further clinical experience is available performance of neuraxial techniques should occur under conditions used in clinical trials (single needle pass, atraumatic needle placement, avoidance of indwelling neuraxial catheters). If this is not feasible, an alternate method of prophylaxis should be considered. (1C)
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5.2 We suggest that neuraxial catheters 6 hours be removed prior to the first (postoperative) dose. (2C)
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6.0 Anesthetic Management of the Patient Receiving Rivaroxaban
6.1 We suggest that rivaroxaban be discontinued 72 hours prior to neuraxial block. Consider checking rivaroxaban or anti–factor Xa activity level if less than 72 hours. An acceptable level of residual rivaroxaban activity to proceed with neuraxial block remains undetermined. (2C)
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6.2 We suggest that neuraxial catheters be removed 6 hours prior to the first (postoperative) dose. (2C)
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6.3 With unanticipated administration with indwelling catheter, we suggest that rivaroxaban dosing be held for 22 to 26 hours before or an anti–factor Xa assay calibrated to rivaroxaban be assessed before the catheter is removed. (2C)
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7.0 AnestheticManagement of the Patient Receiving Apixaban
7.1 We suggest that apixaban be discontinued 72 hours prior to neuraxial block. Consider checking apixaban or anti–factor Xa activity level if less than 72 hours. An acceptable level of residual apixaban activity to proceed with neuraxial block remains undetermined. (2C)
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7.2 We suggest that neuraxial catheters be removed 6 hours prior to the first (postoperative) dose. (2C)
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7.3 With unanticipated administration with indwelling catheter, we suggest that apixaban dosing be held for 26 to 30 hours or an anti–factor Xa assay calibrated to apixaban before the catheter is removed. (2C)
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8.0 AnestheticManagement of the Patient Receiving Edoxaban
8.1 We suggest that edoxaban be discontinued 72 hours prior to neuraxial block. Consider checking edoxaban or anti–factor Xa activity level if less than 72 hours. An acceptable level of residual edoxaban activity to proceed with neuraxial block remains undetermined. (2C)
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8.2 We suggest that neuraxial catheters be removed 6 hours prior to the first (postoperative) dose. (2C)
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8.3 With unanticipated administration with indwelling catheter, we suggest that edoxaban dosing be held for 20 to 28 hours or an anti–factor Xa assay calibrated to edoxaban before the catheter is removed. (2C)
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9.0 Anesthetic Management of the Patient Receiving Betrixaban
9.1 We suggest that betrixaban be discontinued a minimum of 3 days prior to neuraxial block. Consider checking betrixaban or anti–factor Xa level if less than 3 days. (2C)
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9.2 We suggest against the performance of neuraxial blocks in patients with a CrCl of less than 30 mL/min. (2C)
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9.3 We suggest that neuraxial catheters 5 hours be removed prior to next dose. (2C)
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9.4 With unanticipated administration with indwelling catheter, we suggest that betrixaban dosing be held for 72 hours, then the catheter removed. (2C)
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10.0 AnestheticManagement of Patients Receiving Parenteral Thrombin Inhibitors (Desirudin, Bivalirudin, and Argatroban)
10.1 In patients receiving parenteral thrombin inhibitors, we recommend against the performance of neuraxial techniques. (2C)
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11.0 Anesthetic Management of the Patient Receiving Dabigatran
Dabigatran is highly dependent (>80%) on renal excretion. Estimated CrCl tends to overestimate actual renal function. Furthermore, renal function may be further impaired perioperatively.
11.1 We suggest that dabigatran be discontinued 120 hours prior to neuraxial block. However, if renal function has been reliably determined, and there are no additional risk factors for bleeding (eg, age >65 years, hypertension, concomitant antiplatelet medications), a more graded approach may be considered. ()
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11.1.1 We suggest that dabigatran be discontinued 72 hours in patients with a CrCl 80 mL/min or greater. Consider checking dTT or ecarin clotting time (ECT) if less than 72 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)
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11.1.2 We suggest that dabigatran be discontinued 96 hours in patients with a CrCl of 50 to 79 mL/min. Consider checking dTT or ECT if less than 96 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)
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11.1.3 We suggest that dabigatran be discontinued 120 hours in patients with a CrCl of 30 to 49 mL/min. Consider checking dTT or ECT if less than 120 hours. An acceptable level of residual dabigatran activity to proceed with neuraxial block remains undetermined. (2C)
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11.1.4 We suggest against the performance of neuraxial blocks in patients with a CrCl of less than 30 mL/min. (2C)
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11.2 We suggest that neuraxial catheters be removed 6 hours prior to the first (postoperative) dose. (2C)
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11.3 With unanticipated administration with indwelling catheter, we suggest that dabigatran dosing be held for 34 to 36 hours or the dTT or ECT assessed before the catheter is removed. (2C)
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12.0 Regional Anesthetic Management of the Patient on Warfarin
12.1 Caution should be used when performing neuraxial techniques in patients recently discontinued from chronic warfarin therapy. In the first 1 to 3 days after discontinuation of warfarin therapy, the coagulation status (reflected primarily by factors II and X levels) may not be adequate for hemostasis despite a decrease in the INR (indicating a return of factor VII activity). Adequate levels of II, VII, IX, and X may not be present until the INR is within normal limits. We recommend that the anticoagulant therapy must be stopped (ideally 5 days prior to the planned procedure), and the INR normalized prior to initiation of neuraxial block. (1B)
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12.2 We recommend against the concurrent use of medications that affect other components of the clotting mechanisms and may increase the risk of bleeding complications for patients receiving oral anticoagulants and do so without influencing the INR. These medications include aspirin and other NSAIDs, thienopyridines, UFH, and LMWH. (1A)
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12.3 In patients who are likely to have an enhanced response to the drug, we recommend that a reduced dose be administered. (1B)
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12.4 In patients receiving an initial dose of warfarin prior to surgery, we suggest the INR should be checked prior to neuraxial block if the first dose was given more than 24 hours earlier or a second dose of oral anticoagulant has been administered. (2C)
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12.5 In patients receiving low-dose warfarin therapy during epidural analgesia, we suggest that their INR be monitored on a daily basis. (2C)
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12.6 Neurologic testing of sensory and motor function should be performed routinely during epidural analgesia for patients on warfarin therapy. To facilitate neurologic evaluation, we recommend that the type of analgesic solution be tailored to minimize the degree of sensory and motor blockade. (1C)
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12.7 As thromboprophylaxis with warfarin is initiated, we suggest that neuraxial catheters be removed when the INR is less than 1.5. While removal of epidural catheters 12 to 24 hours after warfarin was given does not appear to represent increase risk, the risk of removing epidural catheters at 48 hours is not guaranteed. ()
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12.8 In patients with INR of greater than 1.5 but less than 3, the increase in risk with progressive INR prolongation remains unknown. We suggest indwelling catheters may be maintained with caution, based on INR and duration of warfarin therapy. (2C)
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12.9 In patients with an INR of greater than 3, we recommend that the warfarin dose be held or reduced in patients with indwelling neuraxial catheters (grade 1A). We can make no definitive recommendation regarding the management to facilitate removal of neuraxial catheters in patients with therapeutic levels of anticoagulation during neuraxial catheter infusion. (2C)
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12.10 We suggest that neurologic assessment be continued for at least 24 hours following catheter removal. (2C)
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13.0 Anesthetic Management of the Patient Receiving Antiplatelet Medications
Antiplatelet medications exert diverse effects on platelet function. The pharmacologic differences make it impossible to extrapolate between the groups of drugs regarding the practice of neuraxial techniques. Careful preoperative assessment of the patient to identify alterations of health that might contribute to bleeding is crucial. These conditions include a history of easy bruising/excessive bleeding, female sex, and increased age.
13.1 Nonsteroidal anti-inflammatory drugs
13.1.1 Nonsteroidal anti-inflammatory drugs appear to represent no added significant risk of the development of spinal hematoma in patients having epidural or spinal anesthesia. Nonsteroidal anti-inflammatory drugs (including aspirin) do not create a level of risk that will interfere with the performance of neuraxial blocks. In patients receiving these medications, we do not identify specific concerns as to the timing of single-injection or catheter techniques in relationship to the dosing of NSAIDs, postoperative monitoring, or the timing of neuraxial catheter removal. (1A)
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13.1.2 In patients receiving NSAIDS, we suggest caution in the performance of neuraxial techniques if the concurrent use of other medications affecting clotting mechanisms, such as other (non-NSAID) antiplatelet agents, oral anticoagulants, UFH, and LMWH, is anticipated in the early postoperative period because of the increased risk of bleeding complications. Cyclooxygenase 2 inhibitors have minimal effect on platelet function and should be considered in patients who require anti-inflammatory therapy in the presence of anticoagulation. (2C)
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13.2 Thienopyridines (ticlopidine, clopidogrel, prasugrel)
13.2.1 Preoperative. Based on labeling and surgical/ procedural experience, the recommended time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 10 days for ticlopidine, 5 to 7 days for clopidogrel, and 7 to 10 days for prasugrel. (1C)
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13.2.2 Postoperative. In accordance with ACCP recommendations, thienopyridine therapy may be reinstituted 24 hours postoperatively. (1A)
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13.2.3 Neuraxial catheters should not be maintained with prasugrel or ticagrelor because of the rapid onset. However, because the antiplatelet effect is not immediate with ticlopidine and clopidogrel, neuraxial catheters may be maintained for 1 to 2 days, provided a loading dose of the antiplatelet agent is not administered. (2C)
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13.2.4 Thienopyridine therapy may be resumed immediately after needle placement/catheter removal, provided a loading dose of the drugs is not administered. If a loading dose is administered, we suggest a time interval of 6 hours between catheter removal and administration. (2C)
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13.4 Ticagrelor
13.4.1 Preoperative. Based on labeling and surgical/ procedural experience, the recommended time interval between discontinuation of ticagrelor therapy is 5 to 7 days. (1C)
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13.4.2 Postoperative. In accordance with ACCP recommendations, ticagrelor therapy may be reinstituted 24 hours postoperatively. (1A)
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13.4.3 Neuraxial catheters should not be maintained with ticagrelor because of the rapid onset. (2C)
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13.4.4 Ticagrelor therapy may be resumed immediately after needle placement/catheter removal, provided a loading dose of the drugs is not administered. If a loading dose is administered, we suggest a time interval of 6 hours between catheter removal and administration. (2C)
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13.5 Platelet GP IIb/IIa
The platelet GP IIb/IIIa inhibitors exert a profound effect on platelet aggregation. Following administration, the time to normal platelet aggregation is 24 to 48 hours for abciximab and 4 to 8 hours for eptifibatide and tirofiban.
13.5.1 Preoperative. We recommend that neuraxial techniques should be avoided until platelet function—as impacted by the GP IIb/IIIa inhibitor—has recovered. (Patients are typically on dual therapy and may still have residual NSAID effect.). ()
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13.5.2 Postoperative. Although GP IIb/IIIa antagonists are contraindicated within 4 weeks of surgery, should one be emergently administered in the postoperative period (following a neuraxial technique), we recommend the infusion should be limited to drugs minimizing sensory and motor block to facilitate assessment of neurologic function and that the patient be carefully monitored neurologically (grade 1C). Timing of catheter removal is based on ongoing risk of thromboembolism and need for continued antithrombotic therapy and the potential for spinal bleeding during catheter maintenance and removal. ()
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13.6 Cilostazol
The risk of serious bleeding associated with neuraxial block performed or maintained in the presence of residual cilostazol effect is unknown.
13.6.1 Based on the elimination half-life, we suggest that neuraxial techniques be avoided for 2 days after discontinuation of cilostazol. (2C)
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13.6.2 We suggest that neuraxial catheters be removed prior to reinstitution of cilostazol therapy postoperatively. (2C)
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13.6.3 We suggest that the first postoperative dose of cilostazol be administered 6 hours after neuraxial catheter removal. (2C)
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13.7 Dipyridamole
The risk of dipyridamole in combination with aspirin therapy may represent an increased risk.
13.7.1 Based on the elimination half-life, we suggest discontinuing extended-release dipyridamole for 24 hours prior to neuraxial block. Aspirin may be continued perioperatively. (2C)
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13.7.2 We suggest that neuraxial catheters be removed prior to reinstitution of dipyridamole therapy postoperatively. (2C)
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13.7.3 We suggest that the first postoperative dose of dipyridamole be administered 6 hours after neuraxial catheter removal. (2C)
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13.8 Cangrelor
The risk of serious bleeding associated with neuraxial block performed or maintained in the presence of residual cangrelor effect is unknown.
13.8.1 Based on the elimination half-life, we suggest that neuraxial techniques be avoided for 3 hours after discontinuation of cangrelor. (2C)
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13.8.2 We suggest that neuraxial catheters be removed prior to reinstitution of cangrelor therapy postoperatively. (2C)
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13.8.3 We suggest that the first postoperative dose of cangrelor be administered 8 hours after neuraxial catheter removal. (2C)
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14.0 Anesthetic Management of the Patient Receiving Herbal Therapy
14.1 The use of herbal medications does not create a level of risk that will interfere with the performance of neuraxial block. We recommend against the mandatory discontinuation of these medications or avoidance of regional anesthetic techniques in patients in whom these medications have been administered. (1C)
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15.0 Anesthetic Management of the Anticoagulated Parturient
15.1 Given the limited pharmacologic data on antithrombotic agents in pregnancy and in the absence of a large series of neuraxial techniques in the pregnant population receiving prophylaxis or treatment for VTE, we suggest that the ASRA guidelines be applied to parturients. (2C)
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15.2 However, in circumstances involving select high-risk parturients receiving VTE prophylaxis and requiring urgent interventions for maternal or fetal indications, the risk of general anesthesia may be greater than neuraxial anesthesia, and exceptions/modifications of the ASRA guidelines may be appropriate. (2C)
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16.0 Anesthetic Management of the Patient Undergoing Plexus or Peripheral Block
16.1 For patients undergoing perineuraxial, deep plexus, or deep peripheral block, we recommend that guidelines regarding neuraxial techniques be similarly applied. (1C)
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16.2 For patients undergoing other plexus or peripheral techniques, we suggest management (performance, catheter maintenance, and catheter removal) based on site compressibility, vascularity, and consequences of bleeding, should it occur. (2C)
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Recommendation Grading
Overview
Title
Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy
Authoring Organization
American Society of Regional Anesthesia and Pain Medicine
Publication Month/Year
April 1, 2018
Last Updated Month/Year
August 7, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Evolving standards for the prevention of perioperative venous thromboembolism (VTE) and the introduction of increasingly potent antithrombotic medications have resulted in concerns regarding the heightened risk of neuraxial bleeding. Furthermore, societies and organizations seeking to address these concerns through guidelines in perioperative management have issued conflicting recommendations.
Target Patient Population
Patient on antithrombotic agent receiving regional anesthesia
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Hospital, Operating and recovery room, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D000760 - Anesthesia and Analgesia, D000758 - Anesthesia, D015912 - Thrombolytic Therapy
Keywords
anesthesia, anesthesia and analgesia, Antithrombotic Agents
Source Citation
Reg Anesth Pain Med 2018;43: 263–309