Recommendations

Document Overview

Design and created by Guideline Central in participation with the American Society of Regional Anesthesia and Pain Medicine.

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

American Society of Regional Anesthesia and Pain Medicine

Publication Date: Apr 1, 2018

Page Last Updated: May 5, 2026

ACCP Classification Scheme for Grading Evidence and Recommendations in Clinical Guidelines

ACCP Classification Scheme for Grading Evidence and Recommendations in Clinical Guidelines
Grade	Description	Benefits vs risks and burdens	Methodologic quality of supporting evidence
1A	Strong recommendation, high-quality evidence	Benefits clearly outweigh risks and burdens or vice versa	RCTs without important limitations or overwhelming evidence from observational studies
1B	Strong recommendation, moderate-quality evidence	Benefits clearly outweigh risks and burdens or vice versa	RCTs with important limitations or exceptionally strong evidence from observational studies
1C	Strong recommendation, low-quality or very low quality evidence	Benefits clearly outweigh risks and burdens or vice versa	Observational studies or case series
2A	Weak/Conditional recommendation, high-quality evidence	Benefits closely balanced with risks and burdens	RCTs without important limitations or overwhelming evidence from observational studies
2B	Weak/Conditional recommendation, moderate-quality evidence	Benefits closely balanced with risks and burdens	RCTs with important limitations or exceptionally strong evidence from observational studies
2C	Weak/Conditional recommendation, low-quality or very low quality evidence	Uncertainty in the estimates of benefits, risks, and burdens; benefits, risk, and burden may be closely balanced.	Observational studies or case series
U-CBS	Ungraded consensus-based statement

ACCP: American College of Chest Physicians; RCT: Randomized controlled trial.

Document Overview

Document Title: Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

Authoring Society: American Society of Regional Anesthesia and Pain Medicine

Document Publication Date: Apr 1, 2018

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: rapm.bmj.com/content/rapm/43/3/263.full.pdf

Source Citation: Reg Anesth Pain Med 2018;43: 263–309

Supplemental Implementation Resources

Quick-Reference Guide

Document Scope, Criteria, and Use Cases

Document Objectives: Evolving standards for the prevention of perioperative venous thromboembolism (VTE) and the introduction of increasingly potent antithrombotic medications have resulted in concerns regarding the heightened risk of neuraxial bleeding. Furthermore, societies and organizations seeking to address these concerns through guidelines in perioperative management have issued conflicting recommendations.

Scope: Management

Diseases/Conditions (MeSH)

D000760 - Anesthesia and Analgesia

D000758 - Anesthesia

D015912 - Thrombolytic Therapy

D000760 - Anesthesia and Analgesia

D000758 - Anesthesia

D015912 - Thrombolytic Therapy

Keywords: Antithrombotic Agents, anesthesia, anesthesia and analgesia

Target Patient Population: patient on antithrombotic agent receiving regional anesthesia

Inclusion Criteria: Female, Male, Adolescent, Adult, Older Adult

Health Care Settings: Hospital, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 331

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses conflicts of interest?: No

Includes benefits/harms analysis with recommendations?: Yes

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy

Recommendations

1.0 Administration of Thromboprophylaxis

2.0 Anesthetic Management of the Patient Receiving Thrombolytic Therapy

3.0 Anesthetic Management of the Patient Receiving Unfractionated Heparin

3.3 Intravenous heparin

3.4 Subcutaneous heparin

4.0 Anesthetic Management of the Patient Receiving LMWH

4.5 Preoperative LMWH

4.6 Postoperative LMWH

5.0 Anesthetic Management of the Patient Receiving Fondaparinux

6.0 Anesthetic Management of the Patient Receiving Rivaroxaban

7.0 AnestheticManagement of the Patient Receiving Apixaban

8.0 AnestheticManagement of the Patient Receiving Edoxaban

9.0 Anesthetic Management of the Patient Receiving Betrixaban

10.0 AnestheticManagement of Patients Receiving Parenteral Thrombin Inhibitors (Desirudin, Bivalirudin, and Argatroban)

11.0 Anesthetic Management of the Patient Receiving Dabigatran

12.0 Regional Anesthetic Management of the Patient on Warfarin

13.0 Anesthetic Management of the Patient Receiving Antiplatelet Medications

13.1 Nonsteroidal anti-inflammatory drugs

13.2 Thienopyridines (ticlopidine, clopidogrel, prasugrel)

13.4 Ticagrelor

13.5 Platelet GP IIb/IIa

13.6 Cilostazol

13.7 Dipyridamole

13.8 Cangrelor

14.0 Anesthetic Management of the Patient Receiving Herbal Therapy

15.0 Anesthetic Management of the Anticoagulated Parturient

16.0 Anesthetic Management of the Patient Undergoing Plexus or Peripheral Block

ACCP Classification Scheme for Grading Evidence and Recommendations in Clinical Guidelines

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology