What if catheter removal time is unknown or not documented?

Use a conservative assumption and delay restart until the most conservative gate is satisfied. Update documentation and communicate the new timeline.

Neuraxial/Epidural Timing on Anticoagulants: Catheter Gating Rules

Q: Can I give prophylactic LMWH with an epidural catheter in place?

No. Do not dose anticoagulants while a neuraxial catheter is in place. After removal, the earliest is +4 h for LMWH, then use the later-of rule vs baseline windows.

Q: How long after catheter removal can I restart a UFH infusion?

Earliest is +1 h after removal and only when aPTT is normal. Then take the later of that vs the baseline restart window (24 h for low/moderate risk; 48–72 h for high/neuraxial).

Q: Is neuraxial acceptable with very low CrCl on DOACs?

Avoid neuraxial for dabigatran with CrCl <30. For apixaban <25 or rivaroxaban/edoxaban <30, escalate conservatively and consider alternatives; consult anesthesia/hematology.

Q: Do we bridge DOACs for neuraxial cases?

No. Do not bridge DOACs. For very-high thrombosis risk, involve Hematology instead of defaulting to a bridge.

Q: Does INR govern catheter removal on warfarin?

Yes. Ensure INR <1.5 before catheter removal when feasible and coordinate timing with anesthesia.

Q: What if bleeding risk remains high at the planned restart?

Delay restart. The later-of rule is a minimum; clinical hemostasis overrides. Reassess and document.

Published: September 11, 2025 · Last reviewed: September 11, 2025 · Neuraxial

Short version: With an epidural/spinal/intrathecal catheter, there is no anticoagulant dosing while the catheter is in place. After removal, apply the earliest restart interval (LMWH +4 h; UFH infusion +1 h with normal aPTT; DOACs use a longer, conservative interval) and then take the later of (baseline stop/restart windows by drug/risk/CrCl) vs (removal + interval). Use the calculator to avoid calendar mistakes.

For general planning (non-neuraxial), start with the Conservative Peri-Procedure Plan. For GI work, see DOACs & Endoscopy. Dental? Dental Extractions. Urgent cases? Reversal options. Warfarin governance and bridging? Warfarin: Bridging & INR.

Hard stops & key rules

No dosing with catheter in. For all classes (DOACs, warfarin, LMWH, UFH), do not give anticoagulants while a neuraxial catheter is in place.
Earliest after removal: LMWH +4 h; UFH infusion +1 h (and verify aPTT normal); DOACs: removal + conservative interval (and longer for high/neuro contexts).
Later-of rule: The actual restart is the later of (baseline restart window for the drug/risk/CrCl) or (catheter removal + interval).
Renal cautions: Avoid neuraxial if dabigatran CrCl <30; escalate conservatively if apixaban CrCl <25 or rivaroxaban/edoxaban CrCl <30.
Governance: Do not bridge DOACs. INR <1.5 before catheter removal on warfarin; verify normal aPTT before proceeding on UFH infusion.

Quick reference: baseline vs catheter-gated restarts

Agent / Setting	Baseline stop	Baseline restart	Catheter rule (earliest)	Actual restart
LMWH (therapeutic)	Last dose ≥24 h pre-procedure	24 h (low/mod); 48–72 h (high/neuro)	Removal +4 h	Later of baseline vs (removal +4 h)
LMWH (prophylactic)	Last dose ≥12 h pre-procedure	24 h (low/mod); 48–72 h (high/neuro)	Removal +4 h	Later of baseline vs (removal +4 h)
UFH IV infusion	Stop 4–6 h pre; verify aPTT normal	24 h (low/mod); 48–72 h (high/neuro)	Removal +1 h and aPTT normal	Later of baseline vs (removal +1 h & normal aPTT)
Apixaban / Rivaroxaban / Edoxaban	Shorter for low/mod; longer for high/neuro	24 h (low/mod) vs 48–72 h (high/neuro)	Removal + conservative interval	Later of baseline vs (removal + interval)
Dabigatran (CrCl-tiered)	Longer as CrCl declines	By tier (e.g., 1–2 d low/mod; 2–3 d high; 4–5 d if <30)	Removal + conservative interval	Later of baseline vs (removal + interval)
Warfarin	Typically 5 d pre; check INR	12–24 h (low/mod); 48–72 h (high/neuro)	Ensure INR <1.5 before removal	Later of baseline vs (safe INR & catheter plan)

Need patient-specific timestamps with renal tiers and catheter removal time? Use the AnticoagPlanner calculator. It applies MD Anderson V8 logic with neuraxial gating and warns on hard-stops.

Worked scenarios (calendar logic)

Scenario A — Epidural catheter, therapeutic LMWH

Context: Epidural in situ after major surgery; patient on therapeutic enoxaparin.
Rule: No dosing while catheter in. Remove catheter → wait +4 h.
Restart: Use the later of (baseline window: 48–72 h for high/neuro) vs (removal +4 h). If removal is early, baseline likely dominates.
Tip: If CrCl <30, consider UFH instead of therapeutic LMWH; schedule with anesthesia and pharmacy.

Scenario B — UFH infusion, epidural removal today

Context: UFH infusion for VTE treatment; epidural catheter removal is planned at 10:00.
Rule: Stop UFH → verify aPTT normal → remove catheter → wait +1 h.
Restart: Later of (baseline restart: 24 h low/mod or 48–72 h high/neuro) vs (removal +1 h) and only if aPTT is normal.

Scenario C — Planned spinal, dabigatran CrCl 28

Context: Procedure planned with spinal anesthesia; dabigatran; CrCl 28.
Rule: Avoid neuraxial if possible due to clearance; consider alternative anesthesia/strategy.
If unavoidable: Escalate to anesthesia/hematology; expect long holds; document rationale and risk discussion.

Scenario D — DOAC patient, catheter removal at 18:00

Context: Apixaban patient with epidural; high-risk surgery; catheter removed 18:00.
Rule: Earliest restart is removal + conservative interval (e.g., next evening), but later of this vs baseline 48–72 h governs.
Outcome: If baseline dictates 48–72 h, restart is typically on day 2–3 evening, not simply 24 h post-removal.

Pre-procedure neuraxial checklist

Confirm drug, indication, last dose time, and renal function (CrCl).
Establish procedure risk (low/mod vs high/neuro).
Plan for catheter management (who removes, when, and how documented).
Confirm INR targets for warfarin (e.g., <1.5) and aPTT normalization for UFH infusion.
Set a no-dosing while catheter in place hard-stop in the MAR/order set.
Line up consults (anesthesia/hematology/pharmacy) where appropriate.
Use the calculator for exact timestamps; print or save the plan.

FAQ

Can I give prophylactic LMWH with an epidural catheter in place?

No. Do not dose anticoagulants while a neuraxial catheter is in place. Earliest restart after removal is +4 h for LMWH, then apply the later-of rule vs baseline windows.

How long after catheter removal can I restart a UFH infusion?

Earliest is +1 h after removal and only when aPTT is normal. Then take the later of that vs the baseline restart window (24 h low/mod; 48–72 h high/neuro).

What if the catheter removal time wasn’t charted?

Use a conservative assumption and re-verify with the team. If the exact time is unknown, delay restart until the most conservative gate is satisfied (and update documentation).

Is neuraxial anesthesia ever acceptable with very low CrCl on DOACs?

For dabigatran with CrCl <30, avoid neuraxial if possible. For apixaban <25 or rivaroxaban/edoxaban <30, escalate conservatively and consider alternatives.

Do we bridge DOACs for neuraxial cases?

No. Do not bridge DOACs. For very-high thrombosis risk, involve Hematology rather than defaulting to a bridge.

Does INR govern catheter removal on warfarin?

Yes. Ensure INR <1.5 before catheter removal when feasible and coordinate timing with anesthesia.

What if bleeding risk is still high at the planned restart time?

Delay restart. The later-of rule is a minimum; clinical hemostasis overrides. Document the reassessment and new plan.

Source & governance

Primary: MD Anderson Peri-Procedure Anticoagulants, V8 (approved 07/15/2025).
Catheter timing gaps reflect ASRA-derived institutional guidance where MDACC is silent (e.g., LMWH +4 h; UFH +1 h; warfarin INR target for removal).
This page supports—not replaces—clinical judgment; confirm local policy.

Disclaimer: Educational content for clinicians. Confirm local policy and anesthesia guidance for neuraxial catheters. Use the calculator for exact timestamps with renal/catheter gating.