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Recommended guidelines for performing spinal procedures in anticoagulated patients
Warfarin Discontinue chronic warfarin therapy 4–5 days before spinal procedure and evaluate INR. INR should be within the normal range at time of procedure to ensure adequate levels of all vitamin K-dependent factors. Antiplatelet medications No contraindications with aspirin or NSAIDs. Thienopyridine derivatives (clopidogrel and ticlopidine) should be discontinued 7 days and 14 days, respectively, prior to procedure. GP IIb/IIIa inhibitors should be discontinued to allow recovery of platelet function prior to procedure (8 hours for tirofiban and eptifibatide, 24–48 hours for abciximab). Thrombolytics/fibrinolytics There are no available data to suggest a safe interval between procedure and initiation or discontinuation of these medications. Follow fibrinogen level and observe for signs of neural compression. LMWH Delay procedure at least 12 hours from the last dose of thromboprophylaxis LMWH dose. For “treatment” dosing of LMWH, at least 24 hours should elapse prior to procedure. LMWH should not be administered within 24 hours after the procedure. Unfractionated SQ heparin There are no contraindications to neuraxial procedure if total daily dose is less than 10,000 units. For higher dosing regimens, manage according to intravenous heparin guidelines. Unfractionated IV heparin Delay spinal puncture 2–4 hours after last dose, document normal aPTT. Heparin may be restarted 1 hour following procedure. Note:—NSAIDs indicates nonsteroidal antiinflammatory drugs; GP IIb/IIIa, platelet glycoprotein receptor IIb/IIIa inhibitors; INR, international normalized ratio; LMWH, low-molecular-weight heparin; aPTT, activated partial thromboplastin time. Adapted from: Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003;28:172–97.
