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ANTICOAGULANTS, ANTI-PLATELETS, COAGULOPATHY AND REGIONAL ANAESTHESIA

REGIONAL TECHNIQUE & RISK

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HEPARINS

Check platelet count if heparin given continuously for >3 days to exclude heparin-induced thrombocytopaenia

Unfractionated heparin 5000 IU, subcutaneous (<15000 IU per day)

  • Safe interval prior to neuraxial; 4-6h (ASRA), 4h (ESA), consider confirming  ACT<120s if <6h
  • Safe interval prior to restarting post-neuraxial; immediately (ASRA), 1h (ESA)
  • Safe interval prior to catheter removal; 4-6h (ASRA), 4h (ESA)
  • Safe interval prior to restarting post-catheter removal; 1h (ASRA), immediately (ESA)

Administration with catheter in-situ; doses up to 5000 IU tds subcutaneous deemed safe

Unfractionated heparin >7500 IU, subcutaneous, or >15000 IU/day

  • Safe interval prior to neuraxial; 12h with ACT/aPTT (ASRA), 8-12h (ESA)
  • Safe interval prior to restarting post-neuraxial; 1h (ESA)
  • Safe interval prior to catheter removal; 8-12h (ESA)
  • Safe interval prior to restarting post-catheter removal; 1h (ESA)

Administration with catheter in-situ; not recommended (ASRA, ESA), consider reducing heparin to maximum 5000 IU tds

Unfractionated heparin >10000 IU, subcutaneous, or >20000 IU/day

  • Safe interval prior to neuraxial; 24h with aPTT (ASRA)
  • Safe interval prior to restarting post-neuraxial; 1h (ESA)
  • Safe interval prior to catheter removal; 8-12h (ESA)
  • Safe interval prior to restarting post-catheter removal; 1h (ESA)

Administration with catheter in-situ; not recommended (ASRA, ESA), consider reducing heparin to maximum 5000 IU tds

Unfractionated heparin, intravenous – treatment dosing

  • Safe interval prior to neuraxial; 4-6h with aPTT (ASRA), 4-6h (ESA)
  • Safe interval prior to restarting post-neuraxial; 1h (ASRA & ESA)
  • Safe interval prior to catheter removal; 4-6h with aPTT (ASRA), 4-6h (ESA)
  • Safe interval prior to restarting post-catheter removal; 1h (ASRA & ESA)

Administration with catheter in-situ; caution, ideally >1h if heparin required intraoperatively, consider risk:benefit in the context of a ‘bloody tap’ (ASRA, ESA)

Low molecular weight heparin, enoxaparin – prophylaxis dosing

  • Safe interval prior to neuraxial; 12h (ASRA, ESA)
  • Safe interval prior to restarting post-neuraxial; 12h (ASRA), 4h (ESA)
  • Safe interval prior to catheter removal; 12h (ASRA, ESA), 24h if ‘bloody tap’ (ASRA)
  • Safe interval prior to restarting post-catheter removal; 4h (ASRA, ESA)

Administration with catheter in-situ; prophylactic od dosing considered safe, wait 12h prior to administration, bd dosing not recommended (ASRA), caution, wait 4h prior to administration, max od first 24h (ESA)

Low molecular weight heparin, enoxaparin – treatment dosing

  • Safe interval prior to neuraxial; 24h (ASRA, ESA)
  • Safe interval prior to restarting post-neuraxial; 4h (ASRA, ESRA)
  • Safe interval prior to catheter removal; 24h (ASRA, ESA)
  • Safe interval prior to restarting post-catheter removal; 4h (ASRA, ESA)

Administration with catheter in-situ; not recommended (ASRA, ESA)

Testing for effect

ACT

aPTT

Anti-Xa assay

ROTEM

ORAL ANTICOAGULANTS

Warfarin

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Dabigatran

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Rivaroxaban, apixaban

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Testing for effect

INR

Factor X assay

ROTEM

ANTI-PLATELET AGENTS

NSAIDs; aspirin, ibuprofen, nurofen, diclofenac, indomethacin

No restrictions

Dipyridamole

No restrictions unless in combination with NSAIDs ???SOURCE

Tirofiban

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Abciximab

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Ticagrelor

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Clopidogrel, prasugrel

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Ticlopidine

 

  • Safe interval prior to neuraxial; 
  • Safe interval prior to restarting post-neuraxial;
  • Safe interval prior to catheter removal; 
  • Safe interval prior to restarting post-catheter removal; 

Administration with catheter in-situ;

Testing for effect

aPTT

Platelet function tests

COAGULOPATHY

INR

aPTT

ROTEM

Thrombocytopaenia

Platelet dysfunction

REFERENCES

1. 

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