Anticoagulants and Anaesthesia

When to stop, bridge and restart warfarin, the DOACs, heparins and antiplatelet drugs around surgery and spinal, epidural or deep nerve blocks. Choose the drug and the procedure for a dated plan, or read the tables below. Neuraxial timings follow the ASRA 2025 guidelines, surgical timings CHEST 2022, with the UK and European positions alongside.

When to stop and restart

Anaesthetic
Surgical bleeding risk
Examples

High: major surgery over 45 minutes, cancer, major orthopaedic, cardiac, intracranial or spinal surgery, kidney or liver surgery and TURP. Low or moderate: laparoscopic cholecystectomy, hernia repair, hysterectomy, arthroscopy, hand and foot surgery, endoscopy with biopsy. Minimal: minor dental and skin procedures, cataract surgery, pacemaker insertion (CHEST 2022).

Apixaban (Eliquis)

Warfarin and other vitamin K antagonists

Warfarin (Marevan, Coumadin, Jantoven)

marivan, warfarine, vitamin K antagonist, VKA, coumarin

Usual dose Any maintenance dose, INR target 2–3 or 2.5–3.5

Before a neuraxial or deep block
5 days. INR normal before needle placement (UK: INR 1.4 or less)
Catheter
Case by case. Low-dose warfarin can start with a catheter in place. Check the INR daily and remove the catheter when the INR is below 1.5; at 1.5–3 remove it with caution, and above 3 hold or reduce warfarin.
Next dose
Straight after the block; straight after catheter removal
Before surgery
5 days off. Check the INR the day before surgery. Restart at the usual dose the evening of surgery or the next day. Whether to bridge depends on the thrombotic risk.
Restart after surgery
12–24 h after surgery
UK and Europe
The Association of Anaesthetists accepts an INR of 1.4 or less for neuraxial block. ESAIC/ESRA asks for a normal INR.

Emergency reversal: Emergency surgery: 4-factor prothrombin complex concentrate (25–50 IU/kg, by INR and weight) with vitamin K 5–10 mg IV. If surgery can wait 6–12 hours, IV vitamin K alone may be enough.

Acenocoumarol (Sintrom, Sinthrome)

nicoumalone, vitamin K antagonist, VKA

Usual dose Any maintenance dose

Before a neuraxial or deep block
72 h. INR normal before needle placement
Catheter
Case by case. Manage as for warfarin: daily INR, and remove the catheter when the INR is below 1.5.
Next dose
Straight after the block; straight after catheter removal
Before surgery
3 days off. Its half-life is shorter than warfarin's: CHEST gives 2–3 days off. Check the INR the day before surgery.
Restart after surgery
12–24 h after surgery
UK and Europe
ESAIC/ESRA: about 3 days off, then a normal INR.

Emergency reversal: As for warfarin: prothrombin complex concentrate with IV vitamin K.

DOACs: apixaban, rivaroxaban, edoxaban and dabigatran

Apixaban (Eliquis)

DOAC, NOAC, factor Xa inhibitor, anti-Xa

Low dose 2.5 mg twice daily for VTE prophylaxis after hip or knee replacement

Before a neuraxial or deep block
36 h. If the interval is shorter, check an apixaban level (below 30 ng/mL, or anti-Xa 0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 36 hours before removing the catheter.
Next dose
6 h after the block; 6 h after catheter removal
UK and Europe
ESAIC/ESRA: 36 hours. Association of Anaesthetists (2013): 24–48 hours, next dose 6 hours after the block or catheter removal.

High dose 5 mg twice daily (2.5 mg twice daily when reduced in AF), or 10 mg twice daily at the start of VTE treatment

Before a neuraxial or deep block
72 h. If the interval is shorter, check an apixaban level (below 30 ng/mL, or anti-Xa 0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 72 hours before removing the catheter.
Next dose
24 h after the block; 24 h after catheter removal
Before surgery
1 day off (low or moderate bleeding risk), 2 days off (high). No bridging. PAUSE: 1 day off before low or moderate bleeding risk surgery, 2 days off before high bleeding risk surgery.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
ESAIC/ESRA: 72 hours, or a drug level below 30 ng/mL (a level is needed first when CrCl is below 30 mL/min).

Emergency reversal: Life-threatening bleeding: 4-factor prothrombin complex concentrate (commonly 25–50 IU/kg, per local protocol). Andexanet alfa was withdrawn in the US in December 2025; check whether it is still available locally. Reversal is not used to speed up a planned neuraxial block.

Rivaroxaban (Xarelto)

DOAC, NOAC, factor Xa inhibitor, anti-Xa

Low dose 10 mg once daily for VTE prophylaxis

Before a neuraxial or deep block
CrCl ≥ 30: 24 h; CrCl < 30: 30 h. If the interval is shorter, check a rivaroxaban level (below 30 ng/mL, or anti-Xa 0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 24 hours (30 hours if CrCl is below 30 mL/min) before removing the catheter.
Next dose
6 h after the block; 6 h after catheter removal
UK and Europe
ESAIC/ESRA: 24 hours (30 hours if CrCl is below 30 mL/min). Association of Anaesthetists (2013): 18 hours.

High dose 15 or 20 mg once daily, or 15 mg twice daily at the start of VTE treatment

Before a neuraxial or deep block
72 h. If the interval is shorter, check a rivaroxaban level (below 30 ng/mL, or anti-Xa 0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 72 hours before removing the catheter.
Next dose
24 h after the block; 24 h after catheter removal
Before surgery
1 day off (low or moderate bleeding risk), 2 days off (high). No bridging. PAUSE: 1 day off before low or moderate bleeding risk surgery, 2 days off before high bleeding risk surgery.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
ESAIC/ESRA: 72 hours, or a drug level below 30 ng/mL. Association of Anaesthetists (2013): 48 hours.

Emergency reversal: Life-threatening bleeding: 4-factor prothrombin complex concentrate (commonly 25–50 IU/kg, per local protocol). Andexanet alfa was withdrawn in the US in December 2025; check whether it is still available locally.

Edoxaban (Lixiana, Savaysa)

DOAC, NOAC, factor Xa inhibitor, anti-Xa

High dose 60 mg once daily (30 mg when reduced)

Before a neuraxial or deep block
72 h. If the interval is shorter, check an edoxaban level (below 30 ng/mL, or anti-Xa 0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 72 hours before removing the catheter.
Next dose
24 h after the block; 24 h after catheter removal
Before surgery
1 day off (low or moderate bleeding risk), 2 days off (high). No bridging. 1 day off before low or moderate bleeding risk surgery, 2 days off before high bleeding risk surgery.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
ESAIC/ESRA: 72 hours, or a drug level below 30 ng/mL.

Emergency reversal: Life-threatening bleeding: 4-factor prothrombin complex concentrate (commonly 25–50 IU/kg, per local protocol).

Dabigatran (Pradaxa)

DOAC, NOAC, direct thrombin inhibitor

Low dose 220 mg (or 150 mg) once daily for VTE prophylaxis after hip or knee replacement

Before a neuraxial or deep block
CrCl ≥ 30: 48 h; CrCl < 30: avoid. With CrCl below 30 mL/min, avoid the block unless the dabigatran level is below 30 ng/mL
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 48 hours before removing the catheter.
Next dose
6 h after the block; 6 h after catheter removal
UK and Europe
ESAIC/ESRA: 48 hours.

High dose 150 mg or 110 mg twice daily

Before a neuraxial or deep block
CrCl ≥ 50: 72 h; CrCl 30–49: 5 days; CrCl < 30: avoid. If the interval is shorter, or CrCl is below 30 mL/min, check a dabigatran level (below 30 ng/mL)
Catheter
No doses with a catheter in place. Do not give it with a catheter in place. If a dose is given by mistake, wait 72 hours (120 hours if CrCl is 30–49 mL/min) before removing the catheter.
Next dose
24 h after the block; 24 h after catheter removal
Before surgery
CrCl ≥ 50: 1 day off (low or moderate bleeding risk), 2 days off (high); CrCl < 50: 2 days off (low or moderate bleeding risk), 4 days off (high). No bridging. Dabigatran is cleared by the kidneys, so it needs longer off when CrCl is below 50 mL/min.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
ESAIC/ESRA: 72 hours, or a level below 30 ng/mL (a level is needed when CrCl is below 50 mL/min). Association of Anaesthetists (2013): 48 hours (CrCl above 80), 72 hours (50–80) or 96 hours (30–50).

Emergency reversal: Idarucizumab (Praxbind) 5 g IV reverses dabigatran within minutes. Dabigatran is also removed by haemodialysis.

Heparins and fondaparinux

Low molecular weight heparin (Clexane, Lovenox, Fragmin, Innohep)

LMWH, enoxaparin, dalteparin, tinzaparin, nadroparin, Fraxiparine

Low dose, once daily Enoxaparin 40 mg, dalteparin 5000 IU or tinzaparin 4500 IU once daily

Before a neuraxial or deep block
12 h. If the interval is shorter, consider an anti-Xa level (0.1 IU/mL or less)
Catheter
Can stay in. A catheter can stay in. Give the first dose at least 12 hours after needle placement and the second at least 24 hours after the first. Remove the catheter at least 12 hours after a dose, and give the next dose at least 4 hours after removal.
Next dose
12 h after the block; 4 h after catheter removal
UK and Europe
ESAIC/ESRA: 12 hours, or 24 hours if CrCl is below 30 mL/min. Association of Anaesthetists (2013): 12 hours, next dose 4 hours after the block or catheter removal.

Low dose, twice daily Enoxaparin 30 mg twice daily

Before a neuraxial or deep block
12 h. If the interval is shorter, consider an anti-Xa level (0.1 IU/mL or less)
Catheter
No doses with a catheter in place. Remove the catheter before twice-daily dosing starts. Give the first dose the day after surgery, at least 12 hours after needle placement and at least 4 hours after catheter removal.
Next dose
12 h after the block; 4 h after catheter removal
UK and Europe
ESAIC/ESRA: 12 hours, or 24 hours if CrCl is below 30 mL/min.

High (treatment) dose Enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily; dalteparin 100 IU/kg twice daily or 200 IU/kg once daily; tinzaparin 175 IU/kg once daily

Before a neuraxial or deep block
24 h. If the interval is shorter, consider an anti-Xa level (0.1 IU/mL or less), especially over 75 years or with CrCl 30 mL/min or less
Catheter
No doses with a catheter in place. Do not give a treatment dose with a catheter in place. Remove the catheter at least 4 hours before the first dose, which is at least 24 hours after needle placement.
Next dose
24 h after the block; 4 h after catheter removal
Before surgery
Last dose 24 h before surgery. Give the last dose the morning before surgery, at half the total daily dose. After high bleeding risk surgery, a prophylactic dose can be used for the first 24–72 hours.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
ESAIC/ESRA: 24 hours, or 48 hours if CrCl is below 30 mL/min. Association of Anaesthetists (2013): 24 hours, next dose 4 hours after the block or catheter removal.

Emergency reversal: Protamine partly reverses it: 1 mg per 100 anti-Xa units (1 mg per 1 mg of enoxaparin) given in the last 8 hours, up to 50 mg.

Unfractionated heparin

UFH, heparin sodium, heparin infusion, subcutaneous heparin

Subcutaneous, low dose 5000 units two or three times a day

Before a neuraxial or deep block
4–6 h. Or normal coagulation tests. Check the platelet count if heparin has been given for more than 4 days.
Catheter
Can stay in. A catheter can stay in. Remove it 4–6 hours after a dose; heparin can resume straight after removal.
Next dose
1 h after the block; straight after catheter removal
UK and Europe
ESAIC/ESRA and the Association of Anaesthetists: 4 hours.

Subcutaneous, higher dose 7500–10 000 units twice daily, up to 20 000 units a day

Before a neuraxial or deep block
12 h. Normal coagulation tests if the interval is shorter
Catheter
Case by case. Catheter safety with these doses is not established. Decide case by case, with closer neurological checks and the lowest effective local anaesthetic concentration.
Next dose
No fixed restart interval: decide with the surgical team.
UK and Europe
ESAIC/ESRA: until the aPTT or anti-Xa is normal (about 12 hours after a subcutaneous high dose).

Subcutaneous, very high dose More than 10 000 units a dose or more than 20 000 units a day

Before a neuraxial or deep block
24 h. Normal coagulation tests if the interval is shorter
Catheter
Case by case. Catheter safety with these doses is not established. Decide case by case, with closer neurological checks.
Next dose
No fixed restart interval: decide with the surgical team.

Intravenous infusion Treatment infusion adjusted to the aPTT

Before a neuraxial or deep block
4–6 h. Normal aPTT before needle placement
Catheter
Case by case. An intra-operative heparin bolus can follow needle placement by at least 1 hour. Do not keep a catheter in during a treatment infusion; remove it 4–6 hours after stopping heparin, once coagulation is normal.
Next dose
1 h after the block; 1 h after catheter removal
Before surgery
Last dose 4–6 h before surgery. Restart a treatment infusion without a bolus once haemostasis is secure.
Restart after surgery
24 h after low or moderate bleeding risk surgery, 48–72 h after high
UK and Europe
Association of Anaesthetists (2013): 4 hours or a normal aPTT; heparin 4 hours after catheter removal.

Emergency reversal: Protamine 1 mg per 100 units of heparin given in the last 2–3 hours, up to 50 mg.

Fondaparinux (Arixtra)

factor Xa inhibitor, pentasaccharide

Low dose 2.5 mg once daily

Before a neuraxial or deep block
CrCl ≥ 50: 42 h; CrCl 30–49: 58 h; CrCl < 30: avoid. With normal renal function, 36 hours is enough in younger patients and 42 hours in older patients. If the interval is shorter, check a fondaparinux-calibrated anti-Xa (0.1 IU/mL or less).
Catheter
No doses with a catheter in place. Avoid indwelling catheters. Remove a catheter at least 6 hours before the first dose.
Next dose
6 h after the block; 6 h after catheter removal
UK and Europe
ESAIC/ESRA: 36 hours (72 hours if CrCl is below 50 mL/min). Association of Anaesthetists (2013): 36–42 hours, next dose 6–12 hours after the block.

High dose 5–10 mg once daily by weight (treatment)

Before a neuraxial or deep block
CrCl ≥ 30: 105 h; CrCl < 30: avoid. 70 hours is enough in younger patients and 105 hours in older patients. If the interval is shorter, check a fondaparinux-calibrated anti-Xa (0.1 IU/mL or less).
Catheter
No doses with a catheter in place. Avoid indwelling catheters. Remove a catheter at least 6 hours before the first dose.
Next dose
6 h after the block; 6 h after catheter removal
UK and Europe
ESAIC/ESRA: until the calibrated anti-Xa is 0.1 IU/mL or less (about 4 days).

Emergency reversal: No specific antidote. Protamine has no effect.

Antiplatelet drugs: aspirin, clopidogrel, prasugrel and ticagrelor

Aspirin (Disprin, Ecotrin, Aspro)

acetylsalicylic acid, ASA, NSAID, NSAIDs

Low dose 75–150 mg once daily

Before a neuraxial or deep block
No interval. No interval and no tests. NSAIDs are managed the same way.
Catheter
Can stay in. No restrictions on catheters, their removal or monitoring.
Next dose
Straight after the block; straight after catheter removal
Before surgery
Continue. Continue aspirin for most operations. If bleeding would be catastrophic (for example intracranial surgery), stop it no more than 7 days before.
Restart after surgery
Within 24 h after surgery
UK and Europe
ESAIC/ESRA: no interval for low-dose aspirin (200 mg a day or less). For higher doses, 3 days (with a normal platelet count) to 7 days.

Emergency reversal: Platelet transfusion for serious bleeding.

Clopidogrel (Plavix)

P2Y12 inhibitor, thienopyridine, DAPT, dual antiplatelet therapy

Restart at 75 mg daily 75 mg once daily, restarted without a loading dose

Before a neuraxial or deep block
5–7 days
Catheter
Case by case. A catheter can stay in for 1–2 days after clopidogrel restarts, if no loading dose is given.
Next dose
Straight after the block; straight after catheter removal
Before surgery
5 days off. Restart within 24 hours at the maintenance dose. With a recent coronary stent, do not stop it without the cardiologist.
Restart after surgery
Within 24 h after surgery
UK and Europe
ESAIC/ESRA: 5–7 days. Association of Anaesthetists (2013): 7 days, next dose 6 hours after the block or catheter removal.

Restart with a loading dose 300–600 mg loading dose after surgery

Before a neuraxial or deep block
5–7 days
Catheter
No doses with a catheter in place. Remove the catheter before a loading dose, and give it at least 6 hours after removal.
Next dose
6 h after the block; 6 h after catheter removal
Before surgery
5 days off. Restart within 24 hours. With a recent coronary stent, do not stop it without the cardiologist.
Restart after surgery
Within 24 h after surgery
UK and Europe
ESAIC/ESRA: after a 300 mg loading dose, wait 2 days before a neuraxial block.

Emergency reversal: No antidote. Platelet transfusion for serious bleeding.

Prasugrel (Efient, Effient)

P2Y12 inhibitor, thienopyridine, DAPT, dual antiplatelet therapy

Usual dose 10 mg once daily (5 mg in older or lighter patients)

Before a neuraxial or deep block
7–10 days
Catheter
No doses with a catheter in place. Do not keep a catheter in once prasugrel restarts. Restart straight after removal, or 6 hours after removal if a loading dose is given.
Next dose
Straight after the block; straight after catheter removal
Before surgery
7 days off. CHEST gives 7–10 days off. Restart within 24 hours. With a recent coronary stent, do not stop it without the cardiologist.
Restart after surgery
Within 24 h after surgery
UK and Europe
ESAIC/ESRA and the Association of Anaesthetists (2013): 7 days.

Emergency reversal: No antidote. Platelet transfusion for serious bleeding.

Ticagrelor (Brilique, Brilinta)

P2Y12 inhibitor, DAPT, dual antiplatelet therapy

Usual dose 90 mg twice daily, or 60 mg twice daily long term

Before a neuraxial or deep block
5 days
Catheter
No doses with a catheter in place. Do not keep a catheter in once ticagrelor restarts. Restart straight after removal, or 6 hours after removal if a loading dose is given.
Next dose
Straight after the block; straight after catheter removal
Before surgery
5 days off. CHEST gives 3–5 days off. Restart within 24 hours. With a recent coronary stent, do not stop it without the cardiologist.
Restart after surgery
Within 24 h after surgery
UK and Europe
ESAIC/ESRA and the Association of Anaesthetists (2013): 5 days.

Emergency reversal: No licensed antidote. Platelet transfusion is less effective while ticagrelor is still in the blood.

Cangrelor (Kengrexal, Kengreal)

P2Y12 inhibitor, intravenous antiplatelet

Infusion Intravenous infusion, sometimes used to bridge P2Y12 inhibitors

Before a neuraxial or deep block
3 h
Catheter
No doses with a catheter in place. Remove the catheter before restarting the infusion, and restart it at least 8 hours after removal.
Next dose
8 h after the block; 8 h after catheter removal

Emergency reversal: Platelet function recovers within about an hour of stopping the infusion.

Cilostazol (Pletal)

phosphodiesterase inhibitor

Usual dose 100 mg twice daily

Before a neuraxial or deep block
48 h
Catheter
No doses with a catheter in place. Remove the catheter before restarting, and give the first dose at least 6 hours after removal.
Next dose
6 h after the block; 6 h after catheter removal

Emergency reversal: No antidote.

Glycoprotein IIb/IIIa inhibitors (Integrilin, Aggrastat, ReoPro)

eptifibatide, tirofiban, abciximab, GPIIb/IIIa

Eptifibatide or tirofiban Intravenous infusion

Before a neuraxial or deep block
4–8 h. Wait until platelet function has recovered
Catheter
No doses with a catheter in place. If one is started urgently with a catheter in place, use solutions that spare motor and sensory function and check neurology closely. Time the removal against the thrombotic risk.
Next dose
Decide with the cardiology team.

Abciximab Intravenous bolus and infusion

Before a neuraxial or deep block
24–48 h. Wait until platelet function has recovered
Catheter
No doses with a catheter in place. If it is started urgently with a catheter in place, check neurology closely. Time the removal against the thrombotic risk.
Next dose
Decide with the cardiology team.

Emergency reversal: Eptifibatide and tirofiban wear off within hours of stopping. Platelet transfusion helps after abciximab.

Thrombolytics

Thrombolytics (Actilyse, Metalyse, Rapilysin)

alteplase, tenecteplase, reteplase, streptokinase, fibrinolytic, tPA

Thrombolytic dose Systemic thrombolysis (stroke, PE, MI)

Before a neuraxial or deep block
48 h. Normal coagulation tests, including fibrinogen
Catheter
No doses with a catheter in place. If a thrombolytic is given with a catheter in place, there is no set removal time: measure the fibrinogen and check neurology every 2 hours for at least 48 hours.
Next dose
The original labels advise against thrombolysis within 10 days of puncturing a non-compressible vessel, which includes a neuraxial block.
UK and Europe
Association of Anaesthetists (2013): 10 days.

Emergency reversal: Cryoprecipitate or fibrinogen concentrate and tranexamic acid, guided by fibrinogen.

Bridging anticoagulation: who needs it?

Bridging covers the days off warfarin with heparin. The BRIDGE trial showed that, in atrial fibrillation, it doubles major bleeding without preventing strokes, and CHEST 2022 now suggests against routine bridging for every indication. DOACs are never bridged: they wear off and start working within hours.

High thrombotic risk

  • Mechanical mitral valve, caged-ball or tilting-disc valve, or a stroke or TIA in the last 3 months
  • AF with CHA₂DS₂-VASc 7 or more (CHADS₂ 5–6), a stroke or TIA in the last 3 months, or rheumatic valve disease
  • VTE in the last 3 months, severe thrombophilia (protein C, protein S or antithrombin deficiency, homozygous factor V Leiden or prothrombin mutation, or several defects), antiphospholipid antibodies, or active cancer with a high VTE risk

Consider bridging. CHEST 2022 suggests against routine bridging, even for mechanical valves, because it does not prevent clots and causes bleeding. It does suggest bridging for selected high-risk patients: a mechanical mitral valve with another risk factor, an older-generation valve, a thromboembolic event in the last 3 months, or a previous perioperative thromboembolism.

Moderate thrombotic risk

  • Bileaflet aortic valve with a major stroke risk factor
  • AF with CHA₂DS₂-VASc 5–6 (CHADS₂ 3–4)
  • VTE 3–12 months ago, recurrent VTE, non-severe thrombophilia, or active or recent cancer

No bridging. Do not bridge. Consider it only for a patient with a previous perioperative thromboembolism.

Low thrombotic risk

  • Bileaflet aortic valve without major risk factors
  • AF with CHA₂DS₂-VASc 1–4 (CHADS₂ 0–2) and no previous stroke or TIA
  • VTE more than 12 months ago

No bridging. Do not bridge.

How to bridge warfarin with LMWH

  1. Stop warfarin 5 days before surgery (last dose on day −6).
  2. Start treatment-dose LMWH 3 days before surgery (day −3): enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily, or dalteparin 100 IU/kg twice daily or 200 IU/kg once daily.
  3. Give the last LMWH dose the morning before surgery (day −1, at least 24 hours before), at half the total daily dose.
  4. Restart warfarin the evening of surgery or the next day at the usual dose.
  5. Restart treatment-dose LMWH about 24 hours after low or moderate bleeding risk surgery, or 48–72 hours after high bleeding risk surgery (prophylactic doses in between). Stop it once the INR is in range.

Before a neuraxial block, the last treatment dose of LMWH must be at least 24 hours before the needle, and no treatment dose may be given while a catheter is in place.

Coronary stents: when is elective surgery safe?

Stopping dual antiplatelet therapy early after a stent risks stent thrombosis, which is often fatal. Delay elective surgery until the windows below, continue aspirin through surgery, and stop the P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) only with the cardiologist's agreement. Restart it within 24 hours.

After Delay elective surgery
Balloon angioplasty without a stent At least 14 days
Bare-metal stent At least 30 days
Drug-eluting stent, stable coronary disease Ideally 6 months; time-sensitive surgery after at least 1 month of dual antiplatelet therapy
Any stent after an acute coronary syndrome Ideally 12 months; time-sensitive surgery after at least 3 months of dual antiplatelet therapy

Deep and superficial nerve blocks

Deep blocks, where bleeding is hard to see or compress, follow the neuraxial rules. ESAIC/ESRA 2022 allows superficial, compressible blocks without stopping anticoagulants, with the next dose at the usual time; ASRA 2025 asks you to weigh compressibility, vascularity and the consequences of bleeding. Depth below the skin does not decide the category.

Deep: follow the neuraxial rules

Spinal, epidural, thoracic and lumbar paravertebral, lumbar plexus (psoas compartment), quadratus lumborum, sacral plexus, proximal sciatic, PENG, infraclavicular, deep cervical plexus, stellate ganglion.

Superficial: usually no need to stop

Interscalene, supraclavicular, axillary, forearm, femoral, fascia iliaca, adductor canal, popliteal and subgluteal sciatic, ankle, TAP, rectus sheath, ilioinguinal, erector spinae, serratus anterior, pectoral, parasternal, superficial cervical plexus, peribulbar and sub-Tenon's.

Classification from ESAIC/ESRA 2022 (Table 2). Local practice may differ.

Frequently asked questions

When should warfarin be stopped before surgery?

Stop warfarin 5 days before surgery, so the last dose is on day −6, and check the INR the day before. A neuraxial block needs a normal INR (the Association of Anaesthetists accepts 1.4 or less). Restart warfarin the evening of surgery or the next day at the usual dose. Most patients need no bridging: CHEST 2022 suggests heparin bridging only for selected patients at high thrombotic risk, such as a mechanical mitral valve with another risk factor or a stroke or VTE in the last 3 months.

How long should apixaban (Eliquis) be stopped before a spinal or epidural?

ASRA 2025 suggests 72 hours after a high dose (5 mg or 10 mg twice daily, or 2.5 mg twice daily as a reduced AF dose) and 36 hours after the 2.5 mg twice-daily dose used for VTE prophylaxis. Do not give apixaban with a catheter in place: the first dose after a high dose regimen follows needle placement or catheter removal by at least 24 hours, after a low dose by at least 6 hours. For surgery without a neuraxial block, CHEST 2022 stops it 1 day before low or moderate bleeding risk surgery and 2 days before high bleeding risk surgery.

When should rivaroxaban (Xarelto) be stopped before surgery or a neuraxial block?

For a neuraxial or deep block, ASRA 2025 suggests 72 hours after 15 or 20 mg a day, and 24 hours after the 10 mg prophylactic dose (30 hours if creatinine clearance is below 30 mL/min). For surgery without a neuraxial block, CHEST 2022 stops it 1 day before low or moderate bleeding risk surgery and 2 days before high bleeding risk surgery, and restarts it 24 hours or 48–72 hours after.

How long should dabigatran (Pradaxa) be stopped before surgery?

Dabigatran is cleared by the kidneys, so the interval depends on creatinine clearance. Before surgery, CHEST 2022 gives 1 day off (low or moderate bleeding risk) or 2 days off (high risk) when CrCl is 50 mL/min or more, and 2 or 4 days when it is lower. Before a neuraxial block, ASRA 2025 suggests 72 hours after 110 or 150 mg twice daily (120 hours if CrCl is 30–49 mL/min), and avoiding the block below 30 mL/min unless a drug level is below 30 ng/mL.

When should clopidogrel (Plavix) be stopped before surgery or a spinal anaesthetic?

Stop clopidogrel 5 days before surgery (CHEST 2022) and 5–7 days before a neuraxial or deep block (ASRA 2025). Restart it within 24 hours; without a loading dose it can restart straight after catheter removal, and a catheter can stay in for 1–2 days after restarting. With a recent coronary stent, do not stop it without the cardiologist, and continue aspirin.

Does aspirin need to be stopped before a spinal or epidural?

No. Aspirin and NSAIDs alone do not need stopping before neuraxial blocks or catheter removal (ASRA 2025). CHEST 2022 suggests continuing aspirin for most surgery, stopping it no more than 7 days before only when bleeding would be catastrophic.

When can LMWH be given after a spinal or epidural?

After a low once-daily dose (such as enoxaparin 40 mg), give the first dose at least 12 hours after the needle; the catheter can stay in, remove it at least 12 hours after a dose and give the next dose at least 4 hours after removal. Before the block, wait 12 hours after a low dose and 24 hours after a treatment dose. Treatment doses must not be given with a catheter in place: the first dose comes at least 24 hours after the needle and at least 4 hours after catheter removal.

Do I need to stop anticoagulants for a peripheral nerve block?

Deep blocks, such as lumbar plexus, paravertebral and infraclavicular blocks, follow the neuraxial rules. ESAIC/ESRA 2022 allows superficial, compressible blocks such as axillary, femoral, popliteal sciatic and fascial plane blocks without stopping anticoagulants, with the next dose at the usual time. ASRA 2025 asks you to judge by the site's compressibility, vascularity and the consequences of bleeding.

Sources

Where guidelines differ, the planner uses ASRA for neuraxial and deep blocks and CHEST for surgery, and applies whichever is stricter.

For education only. These timings support, but do not replace, clinical judgement, local policy and discussion with the surgical, cardiology and haematology teams. Weigh each patient's bleeding and thrombotic risk. See also the disclaimer.