Holding Antithrombotics Around Regional Anesthesia:
You’ll hear about appropriate use of antithrombotics around epidurals or spinals due to updated regional anesthesia guidelines.
Spinal or epidural hematomas from regional anesthesia are rare but can lead to paralysis. Hematoma risk goes up when antithrombotics are given around the time of catheter insertion or removal.
Consider the following strategies, along with patient and operative risks when making decisions on the use of anticoagulants around regional anesthesia.
Oral anticoagulants. Stop warfarin about 5 days before catheter insertion. Aim for an INR of 1.2 or less, but INR should not exceed a value of 1.4.
Try to hold most direct oral anticoagulants (DOACs, e.g. rivaroxaban, apixaban) at least 3 days in advance. Lean toward holding dabigatran (Pradaxa) or betrixaban (Bevyxxa) for up to 5 days, depending on renal function.
Wait at least 6 hours after catheter removal before restarting DOACs. Warfarin can be resumed right away due to its slow onset of action.
Heparins. Consider delaying a spinal or epidural catheter until 4 to 6 hours after a 5,000 unit subcutaneous unfractionated heparin (UFH) dose. Wait longer for higher subcutaneous doses.
Stop prophylactic low-molecular-weight heparins (LMWH) such as enoxaparin at least 12 hours in advance and therapeutic LMWH at least 24 hours prior. Consider holding longer when Creatinine Clearance (CrCl) is under 50 mL/min.
After catheter removal, delay giving UFH for at least one hour, but wait at least 4 hours for LMWH. (2 hours was previously advised.)
Antiplatelets. It’s usually okay to continue any dose of aspirin but hold clopidogrel and ticagrelor for 5 to 7 days prior, and prasugrel for at least 7 days prior.
For urgent procedures when antithrombotics cannot be held as long, expect general anesthesia to be used.
Labs, such as anti-Xa levels or platelet function assays, should not be used or relied upon to accurately predict hematoma risk. In addition, it is too soon to say if reversal agents eliminate risk.