Delay intravenous heparin administration for a minimum of 1 hour after needle placement.

It is not recommended to maintain neuraxial or deep plexus catheters in the setting of continuous intravenous heparin administration. In the event of unanticipated heparinization, we recommend monitoring the patient with an indwelling catheter to allow for early detection of motor deficits and consider use of minimal concentration of local anesthetics to enhance early detection of a neuraxial hematoma.

Although the occurrence of a bloody or difficult neuraxial needle placement may increase the risk of hematoma, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is recommended.

It is not recommended to maintain neuraxial or deep plexus/peripheral catheters in the setting of full anticoagulation during cardiac surgery. If unanticipated heparinization occurs, we suggest postoperative monitoring of neurological status and consider use of minimal concentration of local anesthetics to enhance early detection of neuraxial hematoma.

Preoperative low-dose UFH for thromboprophylaxis (5000 U two times per day or three times per day). We suggest needle placement occur a minimum of 4–6 hours after heparin administration or coagulation status be assessed and normal.

Preoperative high dose (7500–10 000 U two times per day or a daily dose of ≤20000 U): We suggest neuraxial block occur a minimum of 12 hours after subcutaneous heparin administration and confirmation of normal coagulation status.

Preoperative high dose (>10000 U subcutaneously per dose, or >20000 U total daily dose): We suggest neuraxial block occur a minimum of 24 hours after subcutaneous heparin administration and confirmation of normal coagulation status.

Postoperative low-dose UFH: There is no contraindication to maintaining neuraxial catheters in the presence of low-dose UFH. We suggest catheter removal occurs a minimum of 4–6 hours after heparin administration. Subsequent heparin administration may occur immediately after catheter removal.

Postoperative high-dose UFH: The safety of indwelling neuraxial catheters in patients receiving doses >5000 U at a time or >15000 U of UFH daily has not been established. We suggest that the risk and benefits be assessed on an individual basis and that techniques to facilitate detection of new/progressive neurological deficits (eg, enhanced neurological monitoring occur and neuraxial solutions to minimize sensory and motor block) be applied.

We recommend that needle placement should occur at least 12 hours after low-dose LMWH.