Patients with Indwelling Epidural and/or Paravertebral Catheters

Patients who require an epidural catheter increasingly have interruptions in pharmacologic prophylaxis, such that epidural catheter placement is now associated with an increased VTE rate, whereas previously this was not the case. 45,46,47,48 Please refer to the JTS Pain, Anxiety, and Delirium CPG for further detail.

1. The timing of administration for chemical VTE prophylaxis may need to be modified to accommodate the placement and/or removal of an epidural.43

- Regional Anesthesia Guidelines recommend a 12-hour interval between enoxaparin dose and epidural placement. After placement, resumption of prophylactic enoxaparin should begin in 12 hours. Before removing the epidural catheter, hold LMWH 12 hours prior to removal. Resumption may start 4 hours after removal. 43,44
  - The maximum recommended prophylactic dose of enoxaparin is 40mg SQ daily.
- For unfractionated heparin, a 4 to 6-hour interval is recommended before epidural placement. After placement, resumption of prophylactic heparin can begin immediately. Before removing the epidural catheter, hold heparin 4-6 hours prior to removal. Resumption may start immediately after removal.
  - The maximum recommended prophylactic dose of heparin is 5000U SQ TID.

2. Avoid missing doses of VTE prophylaxis for epidural placement, if possible.

3. In the combat casualty requiring an epidural pain catheter, modification of enoxaparin dosing to 40mg daily does not increase the incidence of venous thromboembolism.28