Consensus Statement of American Society of Regional Anesthesia (ASRA) on LMWH as it relates to regional anesthetic use, adapted for use in combat casualties.

1. Antiplatelet or oral anticoagulant medications administered in combination with LMWH increases the risk of spinal hematoma. ASRA recommends against concomitant administration of antiplatelet drugs, standard heparin, dextran or coumadin, regardless of LMWH dosing regimen.

2. Before placement of an epidural catheter:

- Prophylactic LMWH should be held for at least 12 hours.
- Therapeutic LMWH should be held for at least 24 hours.

3. With an epidural catheter in place:

- The maximum recommended prophylactic dose of LMWH is 40mg SQ daily
- The initial dose of once daily prophylactic LMWH should not be given until 12 hours after catheter placement. Subsequent daily doses of prophylactic LMWH should start no sooner than 24 hours after the first dose.
- Twice daily dosing of prophylactic LMWH and therapeutic LMWH are not recommended.

4. Before epidural catheter removal:

- Prophylactic LMWH should be held for at least 12 hours.

5. After epidural catheter removal:

- Administration of prophylactic LMWH should be held for at least 4 hours (and at least 12 hours after catheter placement).
- Administration of therapeutic LMWH should be held for at least 4 hours (and at least 24 hours after catheter placement).

6. Neuraxial anesthetic techniques should be avoided in patients who are receiving NSAIDS and LMWH.

7. For patients undergoing deep plexus or deep peripheral blocks, apply neuraxial recommendations

8. For patients undergoing other plexus or peripheral techniques, we recommend management (performance, catheter maintenance, and catheter removal) based on site compressibility, vascularity, and consequences of bleeding, should it occur. Twice daily prophylactic LMWH is acceptable with these types of regional nerve catheters.