DVT prophylaxis, anticoagulation and spinal anaesthesia or spinal cord injured patients

see also:

• DVT prophylaxis
• risk assessment for venous thromboembolism (VTE)
• Western Health DVT prophylaxis and anticoagulation guidelines including peri-operative Mx of those patients on warfarin (pdf) - intranet only

• Consider prophylaxis
• must discuss with trauma and/or neurosurgery units
• Enoxaparin 40mg, subcut 24 hourly
• Consider post acute stage warfarinisation

• As at 2010 for Western Health.
• Patients on full anticoagulation doses of UFH or LMWH uncommonly receive neuraxial anaesthesia/ analgesia.
• A decision to deviate from the following guidelines may be required based on an assessment of Risk vs Benefit.
• This decision will usually be made at Consultant level and the reasons documented.

• In all cases, following the cessation of heparin, a normal APTT is essential prior to needle/catheter insertion for spinal/epidural regional anaesthesia/analgesia.

• A minimum of 6 hours must elapse from the time of ceasing therapeutic UFH infusion and needle/catheter insertion for neuraxial anaesthesia/analgesia. A longer minimum period (e.g. 12 hours) will be required in patients with significant renal impairment.
• The decision to re-commence post-operative therapeutic anticoagulation heparin infusion (no loading dose to be given) should be made in consultation with the Pain Service Consultant, and should be not be commenced sooner than 12 hours post needle/catheter insertion * A longer minimum period (e.g. 24 hours) will be required in patients with significant renal impairment or if blood is present during needle/ catheter placement *
• Removal of an epidural catheter should be timed to occur when the APTT has returned to baselines levels – (approx 3- 4 hours post cessation of infusion)
• Therapeutic UFH infusion may be recommenced 6 hours post catheter removal

• A minimum of 6 hours must elapse from the time of the last prophylactic heparin dose and needle/catheter insertion for spinal/epidural/regional anaesthesia/analgesia. A longer minimum period (e.g. 12 hours) will be required in patients with significant renal impairment.
• Subsequent prophylactic dose of UFH at a minimum of 2 hours post needle/catheter insertion * A longer minimum period (e.g. 12 hours) will be required in patients with significant renal impairment.
• Catheter removal should be timed to occur 6 hours after the last prophylactic dose
• Prophylactic heparin may be recommenced at a minimum of 2 hours post catheter removal

• #The timing of needle/catheter insertion for neuraxial anaesthesia/analgesia may be taken as the documented time of recovery room arrival.
• Pre-procedure anti-Xa level should be performed in particular in the presence of any renal impairment, the elderly (>65) and/or frail patient:

• It is not recommended to perform neuraxial anaesthesia in patients with moderate to severe renal impairment (creatinine clearance ≤ 50mls/min i.e. 0.8 mls/sec) on therapeutic doses of Enoxaparin
• Therapeutic anticoagulation doses of Enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily) do not provide a safe window of opportunity for neuraxial anaesthesia. In patients with normal-mildly reduced renal function (GFR > 50mls/min, or 0.8mls/sec) a minimum of 24 hours must elapse from the last therapeutic anticoagulation dose of Enoxaparin to the time of needle/catheter insertion for neuroaxial anaesthesia/analgesia
• To reduce the potential risk of bleeding associated with the concurrent use of Enoxaparin and neuraxial anaesthesia/ analgesia, the pharmacokinetic profile of the drug should be considered. Placement and removal of the needle/ catheter is best performed when the anticoagulant effect of Enoxaparin is low.
• In patients with normal to mildly reduced renal function (as judged by GFR > 50mls/min or 0.8mls/sec) receiving therapeutic anticoagulation doses of Enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily) placement and removal of epidural &/or spinal needle or catheter requires a delay of 24 hours from the last dose of Enoxaparin.
• The decision to re-introduce Enoxaparin post-operatively MUST be made at Consultant level.
• However subsequent Enoxaparin dose should be given no sooner than 4 hours after spinal needle/ catheter removal or insertion #.
• The patient's regular Enoxaparin dose may need to be delayed to ensure this.
• If blood is present during needle/ catheter placement, the subsequent dose of Enoxaparin should be delayed for 24 hours after placement #.

• Placement of an epidural or spinal needle or catheter should be delayed for at least 12 hours after administration of a VTE prophylactic dose of Enoxaparin, in patients with normal renal function.
• Removal of an epidural catheter should be timed to occur 15 - 18 hours after the last VTE prophylactic dose - Note NOT less than 15 hours
• Subsequent Enoxaparin dose must be deferred for at least 2 hours post removal or insertion # regardless of other guidelines but individual circumstances must be taken into account.

• Neuraxial anaesthesia is not safe in patients on the newer potent anti-platelet agents e.g. clopidogrel (in most cases Clopidogrel should be ceased 7 days pre-operatively