ASRA guidelines: Epid cath removal

ASRA last published guidelines regarding anticoagulation in 2010 (see reference below). What follows is summary of these guidelines. New guidelines will be published in 2014.

Thrombolytics: There is insufficient data to support specific recommendations regarding a safe time period for neuraxial puncture to take place after receiving thrombolytics. If patient has indwelling catheter, ASRA recommends neurologic checks at least every 2 hours and limiting the infusion to drugs that minimize sensory and motor block (grade 1C). There are no recommendations regarding safe timing for removal of a catheter that has been in place after receiving thrombolytics. However, it is recommended that a fibrinogen level be checked prior to removal as this is one of the last clotting factors to recover (grade 2C).

Unfractionated Heparin:If patient has been receiving systemic (therapeutic) heparinization, the heparin should be held for 2 to 4 hours prior to catheter removal, and coagulation status should be checked prior to removal. In patient’s receiving sub-cutaneous (prophylactic) heparin, remove the catheter 2 to 4 hours after the last dose. The next dose of SQH can be given 1 hour after catheter removal. If the patient has been receiving SQH for >4 days, check a platelet count prior to catheter removal (grade 1C).

LMWH:Indwelling catheters can safely be maintained with daily prophylactic dosing, but should not be used if patient is receiving twice-daily dosing. Wait 10-12 hours after the last dose of LMWH prior to removing catheter. The next dose of LMWH can be given 2 hours after catheter removal.

Warfarin:for patient’s receiving warfarin, INR should be < 1.5 prior to catheter removal. Neurologic exams should continue for 24 hours after catheter removal (grade 2C). If the INR is 1.5-3.0, removal of a catheter should be done with caution and neurologic status should continue to be monitored until the INR has stabilized at the desired level (grade 2C). If INR is >3.0, hold warfarin in patients with indwelling catheter (grade 1A).

Anti-Platelet:there are no restrictions on catheter removal in patients receiving NSAIDs/Aspirin (grade 1A).

Thrombin Inhibitors(Desirudin, Lepirudin, Bivalirudin, Argatroban): insufficient evidence regarding neuraxial anesthesia. ASRA recommends against neuraxial techniques (grade 2C).

Fondaparinux:no current recommendations made by ASRA. Recent study of 1631 patients reported no hemorrhagic concerns. Catheters in this study were removed 36 hours after the last dose of fondaparinux and the next was held for 12 hours post-catheter removal.