Antithrombotic/Antiplatelet Agents & Central Neuraxial Blockade
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Blockade Guidelines for Adult Inpatients 18 years and older
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re- starting medication |
|---|---|---|---|
|
Warfarin |
INR < 1.5 and off for 5 days |
No# |
2 hrs |
Heparins
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re- starting medication |
|---|---|---|---|
|
Heparin (treatment) – IV |
6 hrs and aPTT within normal limits |
No |
2 hrs |
|
Heparin (treatment) – SubQ (>5000 Units) |
12 hrs and aPTT within normal limits |
No |
2 hrs |
|
Heparin (prophylaxis) – SubQ % (≤5000 Units) |
4 hrs |
Yes If catheter is placed for surgery, heparin SubQ can be given 60 min after placement+ & |
2 hrs |
|
LMWH (treatment)*, @ Enoxaparin (Lovenox) 1 mg/kg q12h, 1.5mg/kg q24h or 1 mg/kg q24h Dalteparin (Fragmin) @ 120 units/kg q12h or 200 units/kg q24h Tinzaparin (Inohep) 175 units/kg q24h |
CrCl ≥ 30 mL/min: 24 hrs CrCl < 30 mL/min: 48 hrs |
No |
4 hrs |
|
LMWH (prophylaxis)*, @ Enoxaparin ≤ 40 mg SubQ q24h |
12 hrs |
Yes |
4 hrs |
|
Wait 4 hours to restart medication after catheter PLACEMENT |
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|
Wait 12 hours after last dose before catheter REMOVAL |
Factor Xa Inhibitors (also consider thrombotic risk)
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re- starting medication |
|---|---|---|---|
|
Fondaparinux (treatment)* |
72 hrs |
No |
12 hrs |
|
Fondaparinux (prophylaxis)* |
48 hrs |
No |
12 hrs |
|
Rivaroxaban (Xarelto) (treatment) 15-20mg Daily* CrCl ≥ 50 mL/min |
48 hrs |
No |
6 hrs |
|
Rivaroxaban (Xarelto) (treatment) 15-20mg Daily* CrCl < 50 mL/min |
3-5 days |
No |
6 hrs |
|
Rivaroxaban ( Xarelto) (prophylaxis) 10mg Daily |
24 hrs |
No |
6 hrs |
|
Apixaban (Eliquis) (treatment) 2.5-10mg BID* CrCl ≥ 50 mL/min |
48 hrs |
No |
6 hrs$ |
|
Apixaban (Eliquis) (treatment) 2.5-10mg BID* CrCl < 50 mL/min |
3-5 days |
No |
6 hrs$ |
|
Apixaban ( Eliquis) (prophylaxis) 2.5mg BID |
24 hrs |
No |
6 hrs$ |
Antiplatelet Agents
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re-starting medication |
|---|---|---|---|
|
Clopidogrel (Plavix) |
7 days++ |
No |
2 hrs |
|
Prasugrel (Effient) |
7 days |
No |
6 hrs |
|
Cilostazol (Pletal) |
48 hrs |
No |
6 hrs |
|
Dipyridamole/ASA (Aggrenox) |
24 hrs |
No |
2 hrs |
|
Ticagrelor (Brilinta) |
5 days |
No |
6 hrs |
|
Ticlodipine (Ticlid) |
7 days |
No |
2 hrs |
|
Aspirin (> 80mg) |
Not necessary |
Yes |
None |
GP IIb/IIIa inhibitors
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re-starting medication |
|---|---|---|---|
|
Abciximab |
48 hrs |
No |
2 hrs |
|
Eptifibatide* |
8 hrs |
No |
2 hrs |
|
Tirofiban |
8 hrs |
No |
2 hrs |
Thrombolytic Agents
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re-starting medication |
|---|---|---|---|
|
Altepase, Urokinase (treatment) |
12 hrs |
No |
2 hrs |
|
Alteplase, Urokinase (caeter clearance) |
May be given, no time restrictions |
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Direct thrombin Inhibitors (also consider thrombotic risks)^
|
Medication |
Time to wait after last dose of medication before neuraxial needle/ catheter is placed |
Can drug be given when catheter is in place? |
Minimum time to wait AFTER catheter is removed before re- starting medication |
|---|---|---|---|
|
Argatroban, Bilvalirudin |
7 hrs or aPTT within normal limits |
No |
2 hrs |
|
Dabigatran (Pradaxa) CrCl ≥ to 50 mL/min |
48 hrs |
No |
6 hrs$ |
|
Dabigatran (Pradaxa) CrCl < 50 mL/min^ |
3-5 days |
No |
6 hrs$ |
|
LMWH = low molecular weight heparin # For warfarin initiation, catheter may be removed within 24 hours of first dose of warfarin. + Not applicable as e Acute Pain Service standardizes times of catheter insertion and removal around medication administration times. &If pt. has been on heparin therapy for 5 days, recent platelet count is recommended prior to catheter D/C. * Longer times may be warranted in patients wi renal insufficiency % ASRA recommends against TID dosing while catheter is in place. BID dosing and compression devices recommended. $ Twenty four hours if traumatic puncture during placement. ++ If pt. is off of clopidogrel 5-7 days, get “Plavix Assay” which should show < = 20% inhibition in order to proceed wi neuraxial technique. |
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