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I want a 1 page table for recent ASRA guidelines which i can write in my exam Simple easy to reproduce in DNB anaesthesia examination

Reading File
Reading File
Finding Sources
Searching PubMed

regional anesthesia AND anticoagulants

Searching PubMed

regional anesthesia AND anticoagulants

Searching the Web

ASRA fifth edition guidelines regional anesthesia antithrombotic thrombolytic therapy 2025 recommendations tables

Reading Web Page

https://rapm.bmj.com/content/rapm/early/2025/01/21/rapm-2024…

Reading Web Page

https://rapm.bmj.com/content/rapm/early/2025/01/21/rapm-2024…

Finding Sources
Reading Web Page

https://www.guidelinecentral.com/guideline/4293939

ASRA 2025: Neuraxial and Deep Plexus Block in Patients on Antithrombotics

Use for spinal, epidural, CSE, and deep plexus/deep peripheral blocks.
Rule: Time from last dose -> perform block -> safe catheter removal -> time to next dose.
Drug / groupStop before neuraxial blockEpidural catheter / restart
Aspirin, NSAIDsNo interruptionNo special precautions
Clopidogrel5-7 daysCatheter may be maintained for 1-2 days if no loading dose. Restart immediately after catheter removal; if loading dose, wait 6 h
Prasugrel7-10 daysDo not maintain catheter. Restart immediately after removal; loading dose after 6 h
Ticagrelor5 daysDo not maintain catheter. Restart immediately after removal; loading dose after 6 h
WarfarinStop 5 days and ensure INR normalRemove catheter when INR <1.5. Continue neurological observation for 48 h after removal
UFH SC low dose (5000 U BD/TDS)4-6 hRemove catheter 4-6 h after last dose; next UFH after 1 h
UFH IV therapeuticStop 4-6 h, check normal aPTTRemove catheter 4-6 h after last dose; restart after 1 h
LMWH low dose (eg, enoxaparin 40 mg OD / 30 mg BD)12 hOD regimen: remove catheter 12 h after last dose, restart after 4 h. BD regimen: remove catheter before starting LMWH; first dose next day and at least 12 h after needle/catheter placement
LMWH high dose (therapeutic)24 hRemove catheter 4 h before first dose. First dose at least 24 h after needle/catheter placement
DOAC high dose: apixaban, rivaroxaban, edoxaban72 hFirst postoperative dose at least 24 h after needle placement/catheter removal
Dabigatran high doseCrCl >=50: 72 h; CrCl 30-49: 120 h; avoid if CrCl <30First dose at least 24 h after needle placement/catheter removal
DOAC low doseApixaban 36 h; rivaroxaban 24 h; edoxaban 30 h; dabigatran 48 hFirst dose at least 6 h after needle placement/catheter removal
Fondaparinux low dose36 hCatheter removal at least 6 h before next dose
Thrombolytics / fibrinolyticsAvoid neuraxial block for 48 h after therapyIf inadvertently given with catheter in situ: check fibrinogen; frequent neurological monitoring for 48 h after removal

Exam points / precautions

  1. Deep plexus and deep peripheral blocks follow the same timings as neuraxial block.
  2. Aspirin/NSAIDs alone are safe, but combination with anticoagulants increases bleeding risk.
  3. Check platelet count if UFH or LMWH has been used for more than 4 days because of HIT risk.
  4. Avoid traumatic or repeated attempts. If bloody tap occurs, discuss delaying anticoagulant dose with the surgeon.
  5. Monitor for spinal hematoma: new severe back pain, motor weakness, sensory loss, bladder/bowel dysfunction. Urgent MRI and surgical decompression are required.
  6. For DOACs, if an earlier block is unavoidable, an acceptable residual drug level is generally <30 ng/mL or anti-Xa activity <=0.1 IU/mL.
Easy mnemonic:
“Platelets 0-5-7, Heparin 4-6, LMWH 12-24, DOAC 36-72.”
This is based on the ASRA Pain Medicine Evidence-Based Guidelines, 5th edition (2025), which distinguishes low-dose from high-dose DOAC regimens. See the full ASRA guideline and the ASRA guideline summary.
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