Neuraxial Procedures & Anticoagulants: Safe Hold/Restart Windows (MDACC V8 + ASRA)
This original overview summarizes common, conservative practices drawn from MD Anderson’s 2025 algorithm and institutional ASRA-derived catheter timing notes. It is not a reproduction of guideline tables or text. Always confirm hemostasis and local policy.
Recognize neuraxial scenarios
Consider a neuraxial context for neurosurgery or procedures involving epidural, spinal, or intrathecal techniques and for related indications such as lumbar puncture, myelography, deep brain stimulation, or craniotomy. Our calculator auto-detects these keywords and enables catheter timing.
DOACs: general neuraxial guardrails
- Bridging: Do not bridge DOACs. Rare exceptions exist for very high thrombosis risk; discuss with Hematology.
- Renal safety cut-offs: Avoid neuraxial approaches with significant renal impairment (e.g., dabigatran with CrCl <30 mL/min; apixaban with CrCl <25; rivaroxaban/edoxaban with CrCl <30) due to prolonged effect and difficult reversal.
- Catheters: Withhold DOACs while a neuraxial catheter is in place. The earliest safe dose after removal is the later of the baseline post-op window or removal + 24 hours.
Warfarin: neuraxial governance
- Stop 5 days before the procedure and verify INR pre-op. If INR ≥1.5 within 24–48 hours of the procedure, correct or delay.
- For catheter removal, ensure INR <1.5 and coordinate with anesthesia.
- Typical post-op restart in high/neuraxial settings is 48–72 hours once hemostasis is secure.
LMWH and UFH with catheters
- LMWH: No dosing while a catheter is in place. After removal, the first dose should be the later of the baseline window (24 h low/mod; 48–72 h high/neuraxial) or removal + 4 hours. In renal impairment (e.g., CrCl <30) on therapeutic enoxaparin, favor UFH.
- UFH infusion: Hold 4–6 hours pre-procedure and verify aPTT normal. Post-op, resume at the later of the baseline window or removal + 1 hour, confirming aPTT.
Need timestamps and renal/catheter gating? Use the AnticoagPlanner calculator for patient-specific stop/restart plans with explicit sources.
Sources (for verification, not reproduction)
- MD Anderson Cancer Center. Peri-Procedure Anticoagulants, V8 (approved 07/15/2025). Institutional clinical algorithm.
- ASRA/Stanford institutional neuraxial catheter timing summaries (used for catheter removal intervals where institutional norms apply).
Disclaimer: Educational content. This supports, not replaces, clinical judgment. Confirm local policy and anesthesia guidance for neuraxial catheters. Use the calculator for exact timestamps.