The document provides guidelines from the American Society of Regional Anesthesia (ASRA) on placing and removing epidural catheters in patients taking anticoagulant and antiplatelet drugs. It lists recommended minimum times to wait after the last dose of various medications before catheter placement and removal, as well as when to restart anticoagulation therapy after removal. The medications are grouped into heparins, low molecular weight heparins, factor Xa and direct thrombin inhibitors, antiplatelet agents, fibrinolytics, and glycoprotein IIb/IIIa inhibitors. For each group, it provides the drug names and recommended waiting times.

1. ASRA GUIDELINES
GUIDELINES FOR NEURAXIAL ANESTHESIA
AND ANTICOAGULATION
ASRA recommendations for placement & removal of
Epidural Catheter in patient anticoagulant &
Antiplatelet drugs :-

2. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL
When to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
HEPARIN Catheter can be
removed safely,
if the last dose is
given 6 hrs
before
IV
Unfractionated
Heparin
Wait till PTT<40
Usual hold time 4 hrs
2 hrs 1-2 hrs
SC
Unfractionated
Heparin
No contraindication. The risk of neuraxial
bleeding may be reduced by delay of
Heparin injection unit , after the block &
may be increased in debiliated patients after
prolonged therapy.
If Heparin given
> 4 days, do
platelet count
prior to catheter
removal

3. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
LMWH (Low
molecular
weight
Heparin)
Therapeutic
dose
24 hrs 4 hrs Hold time may
be longer in
patients with
renal impairment
. Catheter can be
removed safely,
if the last dose of
LMWH is given
12 hrs before.
4-7 hrs
Enoxaparin
1mg/kg sc QID
or 1.5 mg/kg
daily

4. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
LMWH (Low
molecular
weight
Heparin)
Therapeutic
dose
24 hrs 4 hrs 4-7 hrs
Dalteparin: 120
U/Kg BD in 200
Units/Kg daily

5. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONA
L
INFORMATI
ON
HALF
LIFE
FACTOR X-a
Inhibition
Fondaparinux 72 hrs 12 hrs 17-21
hrs
Rivaroxaban 24 hrs 6 hrs(24 hrs for
traumatic puncture)
Longer hold
time in patients
with renal
impairment
5-9 hrs
Apixaban 48 hrs 6-12 hrs

6. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
DIRECT
THROMBIN
INHIBITORS
Argatroban Wait till APTT<40 2 hrs Longer hold
time in patients
with renal
impairment
40-50
mins
Lepirudin 1-3 hrs
Dabigatran 72 hrs(longer in renal
impairment)
6 hrs(24 hrs for
traumatic puncture)
8-17
hrs

7. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
ANTIPLATEL
ET AGENTS
Aspirin No restrictions No restrictions
Clopidogrel 7-10 days 2 hrs
Dipyridamide 24 hrs
Ticlopidine 10-14days

8. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
FIBRINOLYTI
CS
Streptokinase 10 days 10 days 18-33
mins
Alteplase 26-46
mins
Tenectoplase 115
mins

9. ASRA GUIDELINES
MEDICATION PRIOR TO
CATHETER
PLACEMENT
Minimum time
between the last dose
of anticoagulant &
initial catheter
placement
AFTER
CATHETER
REMOVAL When
to restart
anticoagulation
therapy , once
catheter has been
removed
ADDITIONAL
INFORMATIO
N
HALF
LIFE
GLYCOPROT
EIN IIb/IIIa
INHIBITORS
Abciximab 48 hrs/2 days 2 hrs
Eptifibatide 8 hrs
Tirofiban