Spinal anaesthesia and anticoagulants

‘Spinal anaesthesia’ can refer to either spinal or epidural anaesthesia. The below guidelines clearly summarise safe thresholds around this issue1,2, as there can be misunderstandings.


Antiplatelet drugs

Medication Safe time from last dose to perform spinal
NSAIDs Safe to perform if taken
Aspirin It is safe to perform spinal anaesthesia when aspirin is being taken in isolation
Clopidogrel 7 days
Prasugrel 7-10 days
Ticagrelor 5 days
Tirofiban 8 hours
Eptifibatide 8 hours
Abciximab 48 hours
Dipyridamole Safe to perform if taken


Oral anticoagulants

Medication Safe time from last dose to perform spinal
Warfarin INR < 1.4
Dabigatran

  • CrCl > 80ml/min = 48 hours

  • CrCl 50-80ml/min = 72 hours

  • CrCl 30-50ml/min = 96 hours
Edoxaban 48 hours
Rivaroxaban 48 hours
Apixaban 48 hours


Heparins

Medication Safe time from last dose to perform spinal
Low Molecular Weight Heparin (LMWH)

  • Prophylactic dose (usually 20mg or 40mg OD) = 12 hours

  • Therapeutic dose (1.0-1.5 mg/kg) = 24 hours
Unfractionated heparin (UFH)
  • 4 hours or normal APTR (for prophylactic or therapeutic dose)

References

1.
Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: Recommendations of the european society of anaesthesiology. European Journal of Anaesthesiology| EJA. 2010;27(12):9991015.
2.
Party M of the W, Harrop-Griffiths W, Cook T, et al. Regional anaesthesia and patients with abnormalities of coagulation: The association of anaesthetists of great britain & ireland the obstetric anaesthetists’ association regional anaesthesia UK. Anaesthesia. 2013;68(9):966972.