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