University of Washington Medical Center (UWMC)

VTE ANTICOAGULATION GUIDELINES FOR NEURAXIAL OR PERIPHERAL

NERVE PROCEDURES Guidelines to Prevent Spinal Hematoma following Epidural/Intrathecal/Spinal
Procedures and Perineural Hematoma following Peripheral Nerve Procedures

ATTENTION! WHEN CAN YOU SAFELY DO NEURAXIAL/PERIPHERAL NERVE PROCEDURES OR GIVE ANTICOAGULANTS?
Neuraxial routes include epidural and intrathecal infusions, implanted intrathecal pumps, and spinal injections.
Peripheral routes include all peripheral nerve and plexus infusions. NOTE: Bloody tap/procedure? Anesthesia to call Pain Service

PRIOR TO WHILE AFTER

NEURAXIAL/NERVE NEURAXIAL/NERVE NEURAXIAL/NERVE
MEDICATION PROCEDURE CATHETER IN PLACE PROCEDURE
Minimum time between last dose of Restrictions on use of Minimum time between
anticoagulant and anticoagulants while neuraxial/nerve catheter removal
spinal injection OR neuraxial/nerve neuraxial/nerve catheters are in OR spinal/nerve injection and
catheter placement place and prior to their removal next anticoagulant dose

ANTICOAGULANTS FOR VTE PROPHYLAXIS

heparin unfractionated May be given; no time restrictions for catheter placement/removal or spinal injections
5000 units q8 or q12 hr Do NOT call Pain Service
CONTRAINDICATED
heparin unfractionated while catheter in place: 2 hrs
7500 units SQ q8 hr 8 hrs may NOT be given unless approved
by Pain Service Attending

May be given
dalteparin (Fragmin) BUT:
5000 units SQ qday
12 hrs (longer in renal impairment) •Must wait 8 hrs after catheter 2 hrs
PLACEMENT before giving dose
enoxaparin (Lovenox)
40mg SQ qday •Must wait 12 hrs after last dose
before REMOVING catheter
enoxaparin (Lovenox)
30mg SQ q12 hr or 12 hrs (longer in renal impairment) CONTRAINDICATED
40mg SQ q12 hr while catheter in place: 2 hrs
may NOT be given unless approved
fondaparinux (Arixtra) by Pain Service Attending
< 2.5mg SQ qday 48 hrs (longer in renal impairment)

May be given BUT contact Pain

rivaroxaban (Xarelto) Service regarding dose timing 6 hrs
24 hrs (longer in renal impairment) (per manufacturer
10mg po qday •Must wait 8 hrs after catheter
PLACEMENT before giving dose
recommendations)
•Must wait 24 hrs after last dose
before REMOVING catheter

AGENTS USED FOR FULL SYSTEMIC ANTICOAGULATION

dabigatran (Pradaxa) 72 hrs (longer in renal impairment)
dalteparin (Fragmin)
200 Units/kg SQ qday or 24 hrs (longer in renal impairment)
100 Units/kg SQ q12 hr
enoxaparin (Lovenox) 2 hrs
1.5mg/kg SQ qday or 24 hrs (longer in renal impairment)
1mg/kg SQ q12h CONTRAINDICATED
while catheter in place:
fondaparinux (Arixtra) 72 hrs (longer in renal impairment) may NOT be given
5-10mg SQ qday unless approved by
Pain Service Attending
heparin unfractionated
IV continuous infusion or when aPTT<40 sec
>5000 Units SQ bid or tid
rivaroxaban (Xarelto) 24 hrs (longer in renal impairment) 6 hrs (per manufacturer
15-20mg po qday recommendations)
warfarin (Coumadin) when INR< 1.5 2 hrs

Use with UWMC Nursing Epidural Policy and Procedure (Sheryl Wyant), UWMC Anticoagulation Services www.uwmcacc.org (Ann Wittkowsky), Acute Pain Service (Dermot Fitzgibbon)
and on line Clinical Toolkit: depts.washington.edu/medical/clinicalresources (Tom Staiger).Reference: Horlocher TT et al. Regional anesthesia in the patient receiving antithrombotic or
thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (third edition). Reg Anesth Pain Med 2010; 35:64-101.
www.uwmcacc.org © March 19, 2012 page 1 of 2
 University of Washington Medical Center (UWMC)
VTE ANTICOAGULATION GUIDELINES FOR NEURAXIAL OR PERIPHERAL
NERVE PROCEDURES Guidelines to Prevent Spinal Hematoma following Epidural/Intrathecal/Spinal
Procedures and Perineural Hematoma following Peripheral Nerve Procedures

ATTENTION! WHEN CAN YOU SAFELY DO NEURAXIAL/PERIPHERAL NERVE PROCEDURES OR GIVE ANTICOAGULANTS?
Neuraxial routes include epidural and intrathecal infusions, implanted intrathecal pumps, and spinal injections.
Peripheral routes include all peripheral nerve and plexus infusions. NOTE: Bloody tap/procedure? Anesthesia to call Pain Service

PRIOR TO WHILE AFTER

NEURAXIAL/NERVE NEURAXIAL/NERVE NEURAXIAL/NERVE
MEDICATION PROCEDURE CATHETER IN PLACE PROCEDURE
Minimum time between last dose of Restrictions on use of Minimum time between
anticoagulant and anticoagulants while neuraxial/nerve catheter removal
spinal injection OR neuraxial/nerve neuraxial/nerve catheters are in OR spinal/nerve injection and
catheter placement place and prior to their removal next anticoagulant dose

DIRECT THROMBIN INHIBITORS, INJECTABLE

argatroban
IV continuous infusion CONTRAINDICATED
CONTRAINDICATED
bivalirudin (Angiomax)
when DTI assay < 40 whilewhile catheter
catheter in
in place:
place:
2 hrs
or aPTT < 40 sec may
IV continuous infusion mayNOT
NOTbe begiven
given
unless
unless approved by
approved by
lepirudin (Refludan) Pain
PainService
ServiceAttending
Attending
IV continuous infusion
ANTIPLATELET AGENTS
Aspirin or NSAIDS May be given; no time restrictions for catheter placement or removal
Do NOT call Pain Service
abciximab (Reopro) 48 hrs
aspirin/dipyridamole 7 days
(Aggrenox)
CONTRAINDICATED
clopidogrel (Plavix) 7 days while catheter in place:
may NOT be given 2 hrs
eptifibatide (Integrelin) 8 hrs (longer in renal impairment)
unless approved by
prasugrel (Effient) 7 days Pain Service Attending
ticagrelor (Brilinta) 7 days
tirofiban (Aggrastat) 8 hrs (longer in renal impairment)
THROMBOLYTIC AGENTS
alteplase (TPA) May be given; no time restrictions for catheter placement or removal
2mg dose for catheter clearance (Maximum dose 4mg/24 hours)
CONTRAINDICATED
alteplase (TPA) 10 days while catheter in place: 10 days
full dose for stroke, MI, etc may NOT be given
unless approved by
Pain Service Attending

Use with UWMC Nursing Epidural Policy and Procedure (Sheryl Wyant), UWMC Anticoagulation Services www.uwmcacc.org (Ann Wittkowsky), Acute Pain Service (Dermot Fitzgibbon)
and on line Clinical Toolkit: depts.washington.edu/medical/clinicalresources (Tom Staiger).Reference: Horlocher TT et al. Regional anesthesia in the patient receiving antithrombotic or
thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (third edition). Reg Anesth Pain Med 2010; 35:64-101.
www.uwmcacc.org © March 19, 2012 page 2 of 2