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The
Second American Society of Regional Anesthesia (ASRA) Consensus Conference
on Neuraxial Anesthesia and Anticoagulation
states that spinal and epidural
anesthesia may be used safely with low-molecular-weight heparin (LMWH) given
appropriate timing of LMWH administration in relation to the anesthesia procedure.
Below are summarized the recommendations outlined in the consensus conference
regarding concomitant therapy with LMWH and epidural anesthesia.
Clinical Setting |
Recommendation |
Preoperative, prophylaxis dosed LMWH (eg, enoxaparin 30 mg every 12 hours) |
Place needle at least 10 to 12 hours after last LMWH dose |
Preoperative, treatment dosed LMWH (ie, enoxaparin 1 mg/kg every 12 hours, enoxaparin 1.5 mg/kg daily, dalteparin 120 units/kg every 12 hours, dalteparin 200 units/kg daily or tinzaparin 175 units/kg daily) |
Place needle at least 24 hours after last LMWH dose |
LMWH administered 2 hours preoperatively (eg, general surgery patients) |
Avoid neuraxial techniques as needle placement would occur during peak anticoagulant activity |
Postoperative, receiving single dose or continuous catheter anesthesia to receive twice-daily dosing of LMWH |
Indwelling catheters should be removed prior to LMWH prophylaxis Epidural catheter may be left indwelling overnight and removed the following day, with the first dose of LMWH administered 2 hours after catheter removal Administer LMWH no earlier than 24 hours postoperatively and only in presence of adequate hemostasis |
Postoperative, receiving single dose or continuous catheter anesthesia to receive once-daily dosing of LMWH (ie, dalteparin 2500 units 6 to 8 hours postoperatively then 5000 units every 24 hours) |
Indwelling catheters may be safely maintained Removal of catheter should occur only after a minimum of 10 to 12 hours has elapsed since the last dose of LMWH Administer LMWH 6 to 8 hours postoperatively with the second dose to be given no sooner than 24 hours after the first dose |
Furthermore,
monitoring of the anti-Xa concentration is not recommended, as it is not
predictive of risk of bleeding. ASRA also emphasizes
the importance of awareness
regarding patients’ concomitant medications, such as antiplatelet or
anticoagulant medications, which may
increase the risk of spinal hematoma.
Finally, given the instance of blood being present during needle and catheter
placement,
postponement of surgery is not necessary; however, initiation
of LMWH therapy should be delayed for 24 hours postoperatively.
References
1. Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, et al. Regional anesthesia in the anticoagulated patient: defining the risks (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Regional Anesthesia and Pain Medicine 2003;28(3):172-97.
2. Rowlingson JC, Hanson PB. Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American society of regional anesthesia guidelines. Anesth Analg 2005;100:1482-1488.
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Last Updated: February 12, 2008
