UNFRACTIONATED HEPARIN
 

1. It will be prudent to delay the first dose of such heparin after the block to minimize the chances of bleeding.

2. Continuous SC heparin therapy for more than 4 days can cause thrombocytopenia, so do a platelet count 
   before the neuraxial block is placed.

3. Neuraxial techniques and intraoperative anticoagulation

► Avoid the technique if patient is on other anticoagulants. 
► Heparin to be administered 1 hour after the needle placement. 
► Remove epidural catheter 1 hour before the next dose of heparin. 
► Wait 2-4 hours before removing the epidural catheter if heparin is already given. 
► Stop systemic heparinzation, wait 2-4 hours, evaluate coagulation status before removing the epidural catheter. 
► Do neuro checks
Limit the dose of local anesthetics.
Use epidural narcotics for pain control. 
► Difficult placement or blood in the needle may increase the risk, but case does not have to be cancelled, as there
is no supporting data.  Be advised to use your clinical judgment.

PREOPERATIVE LMWH
This requires coordination and communication.
Monitoring of anti-Xa level is not recommended.

► Single injection spinal anesthetic is the safest but must be done 10-12 hrs after the LMWH dose
        Patients receiving:
	Enoxaparin 1mg/kg x 12hrs
 	Enoxaparin  1.5mg/kg x24 hrs
	Dalteparin  120U/kg x12 hrs
	Dalteparin 200U/kg  x24 hrs
	Tinzaparin 175U/kg x 24 hrs

     Delay neuraxial block for 24 hours

POSTOPERATIVE LMWH

If LMWH is to be started postoperatively:
	LMWH twice a day

► Single injection spinal as well as catheter techniques are okay.
► First dose of LMWH should be given 24 hours postoperatively
► Remove the catheter before starting LMWH, wait 2 hrs and then start LMWH.

► If the dose is already given then wait 10-12 hours to remove the catheter, wait 2 hours and then give the nest dose of LMWH.
LMWH once a day
► First dose should be given 6-8 hours postoperatively
► Second dose should be given 24 hours after the first dose.
► Remove the indwelling catheter only after 10-12 hours after the last dose of LMWH.  Wait 2 hours after removing 
the catheter to administer the next dose of LMWH

CONCURRENT USE OF MEDICATIONS LIKE ORAL ANTICOAGULANTS,
LMWH OR ANTIPLATELET DRUGS WITH HEPARIN MAY INCREASE
THE RISK OF BLEEDING

► Chronic oral anticoagulation: Stop those 4-5 days prior to the procedure, measure PT/INR and perform
 neuraxial block if the PT/INR are within normal limits.
► Postoperatively if anticoagulation is continued monitor PT/INR daily.  This is for the 5 mg dose of warfarin.  Higher doses may
 require more frequent monitoring.
► Neuraxial catheter should be removed when INR is <1.5.
► Neuro checks for 24 hours but longer if INR is >1.5.
► INR >3.0 should alert the physician to decrease the dose of warfarin and delay removing the catheters.

► No single test is available to define platelet activity.
► Spinal and epidurals can be safely done in presence of NSAIDS.
► If used with ticlopidne and clopidogrel and platelet GP IIb/IIIa beware of potential for spinal hematoma. 

Discontinue ticlopidine 14 days before neuraxial block.
Discontinue clopidrogel 7 days before the neuraxial block.
Discontinue eptifibatide 8 hours before the neuraxial block.
Discontinue abciximab 48 hours before the neuraxial block.

Duration action for platelet GP/IIIa inhibitors ranges from 8 hours for eptifibatide to 48 hours for abciximab

NEW ANTICOAGULANTS
FONDAPARINUX

► Actual risk is unknown as it has sustained antithrombotic effect and its irreversibility
► So best is to avoid neuraxial blocks

HERBAL THERAPY

► No significant risk at the present time
► No accepted test for homeostasis
► No specific concerns for the timing of the neuraxial blocks