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Neural blockade and anticoagulation

Anticoagulant	ASRA guideline	Catheter removal	Evidence strength
LMWH	Single preop dose: Delay block 10-12 h. Postop single daily dosing: Delay block 6-8 h. Postop twice daily dosing: Delay block 24 h	Single daily dosing: Remove 10-12 h after last dose; Wait ≥ 2 h before next dose Twice daily dosing: Remove ≥ 2 h before first dose.	Pharmacokinetic data Large series of case reports
Standard heparin	SQ 5,000 U/first dose: Delay heparin for 1-2 h after block. IV/first dose: Delay 1 h after block. IV/continuous: discontinue 2-4 h. Check aPTT prior to block.	Discontinue heparin for 2-4 h Check aPTT prior to removal.	Pharmacokinetic data Prospective and retrospective case surveys and case reports
Warfarin	New dose: check INR if 1^st dose given >24 h before or if 2^nd dose given. Chronic use: discontinue for 4-5 days. Check INR	If used for > 36 h, remove with INR <1.5	Case series and case reports
Aspirin/NSAIDs/COX-2 inhibitors	No issues if patient is not taking other anticoagulants	No issues	Retrospective case surveys
Other antiplatelet agents	Discontinue for: Ticlopidine (Ticlid): 14 days Clopidogrel (Plavix): 7 days Eptifibatide/tirofiban: 8 hrs Abciximab: 48 hrs	No recommendation	Pharmacokinetic data
Thrombolytics/ Fibrinolytics	Avoid a block within 10 days of drug administration. Avoid giving the drugs for 10 days after the block. If block was received around the time drug given, check neurological status ≤ 2 h	No recommendation	Surgical recommendation
Fondaparinux (Arixtra)	Do not combine with neuraxial anesthesia	No recommendation	No data
Herbal supplements	No specific concerns	No issues	No data

The following is a summary of the 2002 ASRA guidelines adapted from Neal JM: Neural blockade and anticoagulation. In: Regional Anesthesia, The requisites in anesthesiology. Rathmel J, Neal J, Viscomi C eds. Elsevier Mosby, Philadelphia, 2004, pages 151-156

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