In this section : Haematology and Thrombosis
Myeloma
Warfarin
Anticoagulation for AF, DVT and PE
Orthopaedic VTE Risk Assessment
Haemolytic Anaemia
Platelet Transfusion
Parenteral Iron in Adults >18 Years
Pulmonary Embolism
Deep Vein Thrombosis of Lower Extremities
Bleeding with Other Antithrombotics
Low Molecular Weight Heparin
Haematinic Testing
Thromboprophylaxis for Non-Covid Patients
Thrombophilia Screening
Antithrombotics in Hip Fracture
Reversal of Warfarin
Lumbar Puncture, Antiplatelet & Anticoagulant Drugs
Antithrombotics & Surgery
Iron Deficiency Anaemia
Unfractionated Heparin Infusion
Massive Pulmonary Embolism
Lumbar Puncture, Antiplatelet & Anticoagulant Drugs
Last updated 7th March 2023
Introduction
- Recommendations for stopping then restarting antithrombotic therapy before and after elective LP and spinal anaesthesia are shown in table below.
- There is very limited evidence for the safety of lumbar punctures/spinal anaesthesia/epidural placement/removal in the emergency situation when anticoagulants/antiplatelets cannot be stopped in the above time.
- It is likely that anticoagulants carry a high risk but of course several can be reversed.
- Antiplatelets (except aspirin) are more contentious, other factors should be considered e.g. operator experience, technical difficulty, other bleeding risks.
- One study – Safety of Lumbar Puncture Performed on Dual Antiplatelet Therapy from the Mayo Clinic Proceedings – demonstrates no complications in 100 outpatients on dual antiplatelets when performed by an experienced nurse.
Drug | Time from last dose of drug until procedure can be safely performed | Time after spinal anaesthesia or lumbar puncture or epidural catheter placement/removal when a drug can be restarted | Time after dose of drug when epidural catheter can be removed | Time after traumatic/multiple puncture when drug can be restarted |
---|---|---|---|---|
Intravenous unfractionated heparin | >4 hours with normal APTTr | >4 hours | NR | >12 hours |
Low molecular weight heparin (prophylactic)* | >12 hours | >4 hours | >12 hours | >24 hours |
Low molecular weight heparin (treatment)* | >24 hours | >4 hours | NR | >24 hours |
Fondaparinux (prophylactic)* | >36 hours | >6 hours | NR | >24 hours |
Fondaparinux (treatment)* | >48 hours | >12 hours | NR | >24 hours |
Warfarin | INR <1.4 | Immediate | NR | >12 hours |
Apixaban | 48 hours | >6 hours | NR | >48 hours |
Edoxaban | 48 hours | >6 hours | NR | >24 hours |
Rivaroxaban | 48 hours | >6 hours | NR | >24 hours |
Dabigatran | CrCl 30-49 - 5days CrCl 50-79 - 4 days CrCl >80 - 3 days | >6 hours | NR | >24 hours |
Aspirin | Continue | Continue | Continue | Continue |
Clopidogrel | 7 days | >6 hours | NR | >24 hours |
Prasugrel | 7 days | >6 hours | NR | >24 hours |
Ticagrelor | 7 days | >6 hours | NR | >24 hours |
Dipyridamole | 24 hours | >6 hours | NR | >24 hours |
Thrombolytic drugs | 10 days | >10 hours | NR | 10 days |
* double times if GFR 15-30; NR not recommended to administer alongside indwelling epidural catheters