In patients with INR >1.5 but <3, the increased risk of maintaining a neuraxial catheter remains unknown. We suggest indwelling catheters may be maintained or removed with caution, closely following the INR and duration of warfarin therapy.

In patients with an INR >3, we recommend that the warfarin dose be held or reduced in patients with indwelling neuraxial catheters.

We can make no definitive recommendation regarding the management to facilitate removal of neuraxial catheters in patients with therapeutic levels of anticoagulation during neuraxial catheter infusion.

We suggest that neurological assessment be continued for at least 48 hours following catheter removal.

Neurological testing of sensory and motor function should be performed routinely during epidural analgesia for patients on warfarin therapy. To facilitate neurological evaluation, we recommend that the type of analgesic solution be tailored to minimize the degree of sensory and motor blockade.

The use of herbal medications does not create a level of risk that will interfere with the performance of neuraxial blocks. We recommend against the mandatory discontinuation of these medications or avoidance of regional anesthetic techniques in patients on these medications.

Given the limited pharmacological data on antithrombotic agents in pregnancy and in the absence of a large series of neuraxial techniques in the pregnant population receiving prophylaxis or treatment for venous thromboembolism, we suggest that the recommendations included in this document be applied to parturients.

However, in circumstances involving select high-risk parturients receiving VTE prophylaxis, and requiring urgent interventions for maternal or fetal indications, the risk of general anesthesia may be greater than neuraxial anesthesia, and exceptions/modifications of these recommendations may be appropriate.

For patients undergoing deep plexus or deep peripheral block, we recommend that guidelines for neuraxial block be similarly applied.

For patients undergoing other plexus or peripheral techniques, we suggest performance, catheter maintenance, and catheter removal be based on site compressibility, vascularity, and consequences of bleeding, should it occur.