Guidelines
for Anticoagulant Management of Patients Requiring
Epidural / Spinal Anaesthesia or
Lumbar Puncture
General Comments
·
The timing of
heparin or LMWH dosing and catheter or needle placement and withdrawal is
critical if patients are also receiving spinal or epidural anaesthesia
·
A pre-operative
dose of LMWH should generally not be given to patients requiring
an epidural anaesthetic
·
For patients on
warfarin the warfarin must be discontinued 4 days prior to the planned
procedure. See Perioperative Management
of Warfarin Patients for more detailed information.
The INR must be < 1.5 prior to insertion of an epidural or spinal needle.
·
Anti-platelet
drugs such as aspirin and NSAID’s when used alone do not preclude the use of
regional anaesthetic techniques.
·
All patients
requiring anticoagulant prophylaxis and regional anaesthesia must be discussed
with an anaesthetist
(1)
Timing of Epidural
Needle / Catheter or Spinal Needle Placement After Anticoagulation
|
Anticoagulant
|
Timing Of Catheter / Needle Placement
|
|
Enoxaparin 20 or 40 mg sc daily (prophylaxis)
|
Minimum of 12 hrs after last dose of enoxaparin
|
|
Enoxaparin 1 mg / kg bd or 1.5 mg / kg / day (treatment)
|
Minimum of 24 hrs after last dose of enoxaparin (omit one dose
of enoxaparin for bd dosing)
|
|
Heparin infusion
|
Minimum of 4 hrs after heparin infusion stopped (APTT in
normal range)
|
·
Spinal needle
also applies to performing a lumbar puncture
(2)
Timing of
First Dose of Anticoagulant or Recommencement of Anticoagulant after Atraumatic
Insertion of an Epidural Needle / Catheter or Spinal Needle
|
Anticoagulant
|
Start Anticoagulant
|
|
Enoxaparin 20 or 40mg sc daily (prophylaxis)
|
Minimum of 4 hrs after insertion of needle/catheter
|
|
Enoxaparin 1 mg / kg bd or 1.5 mg / kg / day (treatment)
|
Minimum of 4hrs after single shot technique
Avoid with continuous epidural analgesia, (use heparin as
an alternative)
|
|
Intra-op / post-op. unfractionated heparin
|
Minimum of 1 hr after needle placement
|
·
Although the
occurrence of a bloody or difficult neuraxial needle placement may increase the
risk of spinal haematoma, there is no data to support mandatory cancellation of
a case. Clinical judgement is needed. If a decision is made to proceed, full
discussion with the surgeons and careful postoperative monitoring are
warranted.
(3)
Timing of First Dose of
Anticoagulant Or Recommencement of Anticoagulant After a Traumatic Needle or
Catheter Placement
|
Anticoagulant
|
Start Anticoagulant
|
|
Traumatic needle or catheter placement (presence of
blood)
|
Enoxaparin (prophylaxis)
|
Minimum of 24 hrs post traumatic needle placement
|
|
Unfractionated heparin
|
Minimum of 2 hrs post traumatic needle
|
(4) Timing of Epidural Catheter Removal and Restarting of
Anticoagulant after Catheter Removal
|
Technique
|
Anticoagulant
|
Timing of Catheter Removal
|
Start Anticoagulant
|
|
Removal of epidural catheter
|
Enoxaparin 20 or 40 mg sc daily (prophylaxis)
|
Minimum of 12 hrs after enoxaparin dose
|
Start enoxaparin a minimum of 4 hrs after removal of
catheter and 24 hrs after the last dose of enoxaparin (if given). Ensure
full neurological function has returned following cessation of epidural
anaesthesia
|
|
|
Enoxaparin 1 mg/kg bd or 1.5 mg/kg/day (treatment)
|
Generally not used with continuous epidural analgesia.
|
Start enoxaparin a minimum of 24 hrs postoperatively and 4
hours after removal of catheter, and only in the presence of adequate
haemostasis
|
|
|
Unfractionated heparin
|
4 hrs after heparin infusion stopped (APTT must be in
normal range)
|
Restart a minimum of 1 hr after
catheter removal
|
Cautions with Heparin or LMWH and Concurrent Treatment:
q Anti-platelet or warfarin therapy
should not be administered in conjunction with heparin or LMWH in patients who
will receive an epidural anaesthetic.
q Patients with traumatic needle or
catheter placement may have an increased risk of spinal haematoma and this
warrants a delay in the first post-operative dose for at least 24 hrs.
Patients receiving LMWH, heparin or
warfarin therapy and epidural anaesthetic should have formal monitoring for:
· New onset or progressive weakness or numbness in the
lower limbs
· Bowel or bladder dysfunction
· New onset back pain
· In view of the importance of monitoring neurological
function LMWH should not be administered before full neurological function has
returned following cessation of an epidural anaesthetic.
|
|
Note: If
there are any doubts, contact the primary surgical team and pain team (93-8724).
|
