Neuraxial Blocks & Anticoagulants

2012 Table: Management of Neuraxial Analgesia & Anticoagulants (pdf file)

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News and Updates:

UnFractionated Heparin:(UFH) Sub Q (Feb 2012, Bolles & Pacini)

The administration of 5000 U of subcutaneous heparin every 12 hours has been used extensively for prophylaxis against DVT. More recently we have noticed an increase in the treatment use of subcutaneous UFH 5000 U every 8 hours or 7500 U every 12 hours. 

The ASRA guidelines state that in patients receiving prophylaxis with dosing regimens of 5000 U twice daily, there is no contraindication to the use of neuraxial techniques. ASRA does recommend however, that patients receiving heparin for more than 4 days have a platelet count assessed before neuraxial block and/or catheter removal. 

Regarding dosing regimens of >10,000 U, ASRA states that the safety has not been established. They advise the risk/benefit be assessed on an individual basis and techniques to facilitate detection of neuro deficits should be employed. Two years ago, revisions were completed with the addition to our epidural order sets that include neurological monitoring every 4 hours in all patients with indwelling epidural catheters and neurological monitoring to continue for 3 hours following the removal of an epidural catheter. 

Upon further discussion with other institutions regarding their practice of increased dosing of subcutaneous UFH(>10,000 U/24 hours) and neuraxial techniques, we (Jim Pisini and Tom Bolles) have made the following practice guideline changes:


Unfractionated subcutaneous heparin: In patients receiving prophylaxis with subcutaneous UFH with dosing regimens of 5000 U twice daily, there is no contraindication to the use of neuraxial techniques. For patients receiving doses greater than 10,000 U of UFH daily or more than twice daily, manage according to UFH intravenous guidelines.


Unfractionated IV heparin: Delay needle/catheter placement 4 hours after last dose, document normal aPTT. UFH may be restarted 2 hours following procedure. Sustained heparinization in the presence of an indwelling neuraxial catheter is potentially associated with increased risk; monitor neurologic status aggressively.


IS is developing a new order to facilitate our request to "hold morning dose of subcutaneous UFH" in anticipation of epidural catheter removal the following day (patients receiving doses greater than 10,000 U daily or more than twice daily dosing). This order will be available in the browse under Pain Management->APMS->EPIDURAL CATHETER PLACEMENT/REMOVAL. This order should be completed by next week. 

Regarding epidural placement for inpatients, we will need to be diligent preoperatively in reviewing all anticoagulation orders. Please hold the morning dose of subcutaneous UFH on the day of surgery, if the patient is receiving doses greater than 10,000 U daily or more than twice daily dosing. Recommend documenting a normal aPTT.

Thank you,
Paula