High-dose fondaparinux: We suggest testing aXa activity calibrated to fondaparinux if placing needle prior to the recommended times is considered (aXa ≤0.1 IU/mL).

We suggest that neuraxial catheters be removed at least 6 hours prior to the first postoperative dose.

In patients scheduled to receive thrombolytic therapy, we recommend that the patient be queried, and the medical record reviewed for a recent history of lumbar puncture, spinal or epidural anesthesia, or epidural steroid injection to allow appropriate monitoring. Guidelines detailing original contraindications for thrombolytic drugs suggest avoidance of these drugs for 10 days following puncture of non-compressible vessels.

In patients who have received fibrinolytic and thrombolytic drugs, we recommend against needle placement for at least 48 hours. Documentation of normalization of clotting studies (including fibrinogen) is suggested.

In those patients who have received neuraxial blocks at or near the time of fibrinolytic and thrombolytic therapy, we recommend that frequent neurological monitoring (eg, every 2 hours) should be continued for at least 48 hours after the last dose. If neuraxial blocks have been combined with fibrinolytic and thrombolytic therapy and ongoing epidural catheter infusion, we recommend the infusion should be limited to drugs minimizing sensory and motor block to facilitate assessment of neurological function.

There is no definitive recommendation for removal of neuraxial catheters in patients who unexpectedly receive fibrinolytic and thrombolytic therapy during a neuraxial catheter infusion. We suggest the measurement of fibrinogen level (one of the last clotting factors to recover) to evaluate the presence of residual thrombolytic effect and appropriate timing of catheter removal. Patients should have frequent neurological monitoring for at least 48 hours following catheter removal.

We recommend that the anticoagulant therapy be stopped 5 days prior to the planned procedure, and the INR be measured and normalized (normal range of the local laboratory) prior to needle placement.

In patients receiving an initial dose of warfarin prior to surgery, we suggest the INR should be checked prior to needle placement if the first dose was given >24 hours earlier, or if a second dose of oral anticoagulant has been administered.

In patients receiving low-dose warfarin therapy during epidural analgesia, we suggest that their INR be monitored daily.

We suggest that neuraxial catheters be removed when the INR is <1.5.