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ASRA GUIDELINES
GUIDELINES FOR NEURAXIAL ANESTHESIA
AND ANTICOAGULATION
ASRA recommendations for placement & removal of
Epidural Catheter in patient anticoagulant &
Antiplatelet drugs :-
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL
When to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
HEPARIN Catheter can be
removed safely,
if the last dose is
given 6 hrs
before
IV
Unfractionated
Heparin
Wait till PTT<40
Usual hold time 4 hrs
2 hrs 1-2 hrs
SC
Unfractionated
Heparin
No contraindication. The risk of neuraxial
bleeding may be reduced by delay of
Heparin injection unit , after the block &
may be increased in debiliated patients after
prolonged therapy.
If Heparin given
> 4 days, do
platelet count
prior to catheter
removal
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
LMWH (Low
molecular
weight
Heparin)
Therapeutic
dose
24 hrs 4 hrs Hold time may
be longer in
patients with
renal impairment
. Catheter can be
removed safely,
if the last dose of
LMWH is given
12 hrs before.
4-7 hrs
Enoxaparin
1mg/kg sc QID
or 1.5 mg/kg
daily
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
LMWH (Low
molecular
weight
Heparin)
Therapeutic
dose
24 hrs 4 hrs 4-7 hrs
Dalteparin: 120
U/Kg BD in 200
Units/Kg daily
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONA
L
INFORMATI
ON
HALF
LIFE
FACTOR X-a
Inhibition
Fondaparinux 72 hrs 12 hrs 17-21
hrs
Rivaroxaban 24 hrs 6 hrs(24 hrs for
traumatic puncture)
Longer hold
time in patients
with renal
impairment
5-9 hrs
Apixaban 48 hrs 6-12 hrs
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
DIRECT
THROMBIN
INHIBITORS
Argatroban Wait till APTT<40 2 hrs Longer hold
time in patients
with renal
impairment
40-50
mins
Lepirudin 1-3 hrs
Dabigatran 72 hrs(longer in renal
impairment)
6 hrs(24 hrs for
traumatic puncture)
8-17
hrs
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
ANTIPLATEL
ET AGENTS
Aspirin No restrictions No restrictions
Clopidogrel 7-10 days 2 hrs
Dipyridamide 24 hrs
Ticlopidine 10-14days
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
FIBRINOLYTI
CS
Streptokinase 10 days 10 days 18-33
mins
Alteplase 26-46
mins
Tenectoplase 115
mins
ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
GLYCOPROT
EIN IIb/IIIa
INHIBITORS
Abciximab 48 hrs/2 days 2 hrs
Eptifibatide 8 hrs
Tirofiban

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ASRA Guidelines

  • 1. ASRA GUIDELINES GUIDELINES FOR NEURAXIAL ANESTHESIA AND ANTICOAGULATION ASRA recommendations for placement & removal of Epidural Catheter in patient anticoagulant & Antiplatelet drugs :-
  • 2. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE HEPARIN Catheter can be removed safely, if the last dose is given 6 hrs before IV Unfractionated Heparin Wait till PTT<40 Usual hold time 4 hrs 2 hrs 1-2 hrs SC Unfractionated Heparin No contraindication. The risk of neuraxial bleeding may be reduced by delay of Heparin injection unit , after the block & may be increased in debiliated patients after prolonged therapy. If Heparin given > 4 days, do platelet count prior to catheter removal
  • 3. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE LMWH (Low molecular weight Heparin) Therapeutic dose 24 hrs 4 hrs Hold time may be longer in patients with renal impairment . Catheter can be removed safely, if the last dose of LMWH is given 12 hrs before. 4-7 hrs Enoxaparin 1mg/kg sc QID or 1.5 mg/kg daily
  • 4. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE LMWH (Low molecular weight Heparin) Therapeutic dose 24 hrs 4 hrs 4-7 hrs Dalteparin: 120 U/Kg BD in 200 Units/Kg daily
  • 5. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONA L INFORMATI ON HALF LIFE FACTOR X-a Inhibition Fondaparinux 72 hrs 12 hrs 17-21 hrs Rivaroxaban 24 hrs 6 hrs(24 hrs for traumatic puncture) Longer hold time in patients with renal impairment 5-9 hrs Apixaban 48 hrs 6-12 hrs
  • 6. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE DIRECT THROMBIN INHIBITORS Argatroban Wait till APTT<40 2 hrs Longer hold time in patients with renal impairment 40-50 mins Lepirudin 1-3 hrs Dabigatran 72 hrs(longer in renal impairment) 6 hrs(24 hrs for traumatic puncture) 8-17 hrs
  • 7. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE ANTIPLATEL ET AGENTS Aspirin No restrictions No restrictions Clopidogrel 7-10 days 2 hrs Dipyridamide 24 hrs Ticlopidine 10-14days
  • 8. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE FIBRINOLYTI CS Streptokinase 10 days 10 days 18-33 mins Alteplase 26-46 mins Tenectoplase 115 mins
  • 9. ASRA GUIDELINES MEDICATION PRIOR TO CATHETER PLACEMENT Minimum time between the last dose of anticoagulant & initial catheter placement AFTER CATHETER REMOVAL When to restart anticoagulation therapy , once catheter has been removed ADDITIONAL INFORMATIO N HALF LIFE GLYCOPROT EIN IIb/IIIa INHIBITORS Abciximab 48 hrs/2 days 2 hrs Eptifibatide 8 hrs Tirofiban