Conservative Peri-Procedure Plan: Safe Stop and Restart Windows
Goal: give teams a conservative, neuraxial-safe way to set hold and restart windows for DOACs, warfarin, and heparins. No dosing. No patient-specific advice. Use this as a planning frame and confirm local policy.
Why a conservative plan
Short holds lower clot risk. Extra time lowers bleed risk. A conservative plan balances both by using known risk tiers, renal function, and neuraxial gating. It also avoids bridging unless there is a clear indication.
The frame we use
- Procedure bleed risk (low or moderate vs high or neuraxial).
- Drug class (apixaban, rivaroxaban, edoxaban, dabigatran, warfarin, LMWH, UFH infusion).
- Renal function for renally cleared agents (CrCl tiers).
- Neuraxial status and catheter removal timing.
DOACs
- General windows: many low or moderate risk cases use about 24 hours for apixaban, rivaroxaban, or edoxaban. High bleed or neuraxial contexts often need 48–72 hours. Dabigatran needs longer when CrCl is low.
- No bridging: do not bridge DOACs. If very high thrombotic risk is claimed, seek Hematology input rather than defaulting to a bridge.
- Neuraxial hard stops: no DOAC dosing while a catheter is in. Earliest restart is removal plus a safe interval. The real restart is the later of that interval or the baseline window.
Warfarin
- Hold: commonly 5 days before the procedure with an INR check prior to the case. Target is usually below 1.5.
- Restart: 12–24 hours after low or moderate risk work if hemostasis is secure. 48–72 hours for high bleed or neuraxial contexts.
- Bridging: not default. Reserve for high or very high thrombotic risk. Choice of LMWH vs UFH should account for renal function and logistics.
LMWH and UFH
- Therapeutic LMWH: last dose at least 24 hours pre-procedure. Restart 24 hours after low or moderate risk cases or 48–72 hours after high bleed or neuraxial cases if hemostasis is secure.
- Prophylactic LMWH: last dose at least 12 hours pre-procedure. Restart on a similar low vs high bleed schedule as above.
- UFH infusion: stop 4–6 hours before the case. Verify aPTT is in the normal range before proceeding. Restart 24 hours for low or moderate risk, 48–72 hours for high or neuraxial cases once hemostasis is secure.
- Neuraxial gating: LMWH earliest restart is removal plus 4 hours. UFH earliest restart is removal plus 1 hour. No anticoag dosing while any catheter is in.
How to use this with the calculator
Open the planner, choose the procedure type and risk, pick the drug, add the procedure date and time, and enter renal data. The output shows warnings, a conservative stop time, and a safe restart time. Neuraxial fields are gated so that restart never occurs while a catheter is in place.
Governance notes
- Use institutional policy and consult anesthesia for neuraxial cases.
- Do not bridge DOACs. Warfarin bridging is for selected high risk cases only.
- Restart only when hemostasis is secure.
Sources
- Primary: MD Anderson Peri-Procedure Anticoagulants, V8, approved 07/15/2025. Appendix and tables for DOACs, warfarin, heparins.
- Neuraxial intervals cross-referenced to ASRA institutional summaries for catheter management.
Disclaimer: Educational content. This supports, not replaces, clinical judgment. Confirm local policy and anesthesia guidance for neuraxial catheters.