TABLE

ATTENTION! WHEN CAN YOU SAFELY DO NEURAXIAL/PERIPHERAL NERVE PROCEDURES OR GIVE ?

After Neuraxial procedure/catheter Prior to Procedure While Neuraxial/nerve catheter is in place removal

Minimum time between last dose of anticoagulant and neuraxial Restrictions on use of anticoagulants with neuraxial/nerve catheters in Minimum time between catheter remove or neuraxial procedure procedure place and next dose of anticoagulant

ANTICOAGULANTS FOR VTE PROPHYLAXIS 2 hrs unfractionated No contraindication w/ twice-daily dosing and total daily dose < 10,000 units Check platelet count prior to removing catheter 5000 units SQ BID if on SQ heparin > 4 days

2 hours heparin unfractionated 8 hrs CONTRAINDICATED > 5000 units SQ TID Check platelet count prior to removing catheter if on SQ heparin > 4 days

May be given BUT contact dalteparin (Fragmin) Anesthesiologist regarding dose timing 5000 units SQ qday *Must wait 6 - 8 hrs after catheter 12 hrs (longer in renal impairment) 4 hours PLACEMENT before giving dose enoxaparin (Lovenox) 40mg SQ qday *Must wait minimum of 12 hours 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: 4 hours IF inadvertently administered while catheter (Arixtra) 48 hrs (longer in renal impairment) is in place, wait a minimum of 12 hrs < 2.5mg SQ qday after last dose before removing catheter ANTI - Xa AGENTS

(Xarelto) 10mg po qday

Contraindicated 3 days 6 hours OK for Peripheral Nerve Catheters

(Eliquis)

AGENTS USED FOR FULL SYSTEMIC ANTICOAGULATION (Pradaxa) 4 days Contraindicated 6 hrs (usually 20 mg PO qhs) 6 days - renal disease OK for Peripheral Nerve Catheters

dalteparin (Fragmin) 200 Units/kg SQ qday or 100 Units/kg SQ q12 hr CONTRAINDICATED If inadvertently administered while catheter is in tinzaparin 175 units/kg 24 hrs (longer w/ renal impairment) place, wait a minimum of 24 hrs before 4 hrs enoxaparin (Lovenox) removing catheter 1.5mg/kg SQ qday or 1mg/kg SQ q12h fondaparinux (Arixtra) CONTRAINDICATED If inadvertently administered while catheter 5-10mg SQ qday 48 hrs 24 hrs is in place, wait a minimum of 12 hrs before removing catheter 2 hr CONTRAINDICATED: If systemic heparin is inadvertently started PRIOR to heparin unfractionated when aPTT<40 sec Frequent neuro checks IV continuous infusion removal, hold heparin for 2-4 hrs and recheck (at least q 2hrs) anticoagulation status for 24 hrs Remove when INR <1.5. Continue neuro assessments for 24 hrs after removal. When INR < 1.5. CONTRAINDICATED warfarin (Coumadin) Should be discontinued at least 4-5 days prior to INR>1.5 but < 3: remove w/ caution. OK for Peripheral Nerve Catheters procedure Frequent neuro checks until INR <1.5 INR >3: Hold . Wait to remove catheter until INR decreases DIRECT INHIBITORS

4 days dabigatran (Pradaxa) 6 days - renal disease CONTRAINDICATED 6 hrs (usually 20 mg PO qhs)

CONTRAINDICATED IV continuous infusion 4-6 hrs or (Angiomax) while catheter in place: 2 hrs aPTT < 40 sec IV continuous infusion 18 hrs if HD dependent lepirudin (Refludan) IV continuous infusion ANTIPLATELET AGENTS / Aggrenox (Dypridamole/ASA) 7 Days CONTRAINDICATED 24 hrs Aspirin (81 or 325 mg dose) No time restrictions Yes if no concurrent anticoagulants used May resume immed after removal NSAIDS / Cox-2 inhibitors NSAIDS by themselves do not increase the risk of neuraxial hematoma. (Reopro) 5 days 8 hrs 12 hrs - 75 mg dose 7 days (Plavix) 24 hrs >300 mg dose (Integrelin) 24 hrs 8 hrs (Effient) 7 days (Brillinta) 5 days CONTRAINDICATED 24 hrs (Kengreal) 1 hour (Zontivity) 28 days Pentoxifylline (Trental) 7 days 2 hrs (Pletal) 4 days (Ticlid) 14 days (Aggrastat) 24 hrs 8 hrs THROMOLYTIC AGENTS (TPA) May be given; no time restrictions for catheter placement or removal 2mg dose for catheter clearance (Maximum dose 4mg/24 hours)

alteplase (TPA) 10 days CONTRAINDICATED 10 days full dose for stroke, MI, etc.

Other Garlic Approximately 7 days to normal hemostasis after discontinuation Ginko Approximately 36 hrs to normal hemostasis after discontinuation Ginseng Approximately 24 hrs to normal hemostasis after discontinuation

AREA: Clinical Practice Effective Date:2/1/2014 POLICY NUMBER: CP‐M‐7.00 REVIEWED/UPDATED: 10/19/2016, 4/2017 AUTHOR(S): Faisal Choudhry, MD APPROVED BY: Faisal Choudhry, MD ‐ AAPA Medical Director WEBSITE UPDATED: 5/3/2017 APPLIES TO: All Sites © AAPA 2014