10 to 12 hours 2 hours
• Before surgery, wait at least 10 to 12 hours after the last dose of LMW heparin is administered before a spinal/epidural catheter is placed. • After surgery, when there is adequate surgical site hemostasis, wait at least six to eight hours after catheter removal before resuming treatment with LMW heparins. ● LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours [ 7,58,62 ]. ► Avoid the technique if patient is on other anticoagulants. ► Heparin to be administered 1 hour after the needle placement. ► Remove epidural catheter 1 hour before the next dose of heparin. ► Wait 2-4 hours before removing the epidural catheter if heparin is already given. ► Stop systemic heparinzation, wait 2-4 hours, evaluate coagulation status before removing the epidural catheter. ► Do neuro checks Limit the dose of local anesthetics. If a prophylactic dose of a low-molecular-weight heparin such as dalteparin or enoxaparin is used, the surgery could be performed safely as early as 12 hours after the dose is given. With fondaparinux, however, it may not be safe to proceed under neuroaxial blockade, even at 24 hours, as it has a half-life of 18 hours.  Maximum initial dose 1000 units/hr aPTT (sec) REPEAT BOLUS (if ordered) Maintenance Infusion Dosage Change NEXT aPTT After Change Acute STEMI in (Goal) NONE STOP x 1 hour, then  by 3 units/kg/hr 6 hours WARFARIN — Recommendations for Management of Supratherapeutic INRs. Monitor and repeat as needed. WARFARIN (Coumadin ® , Jantoven ®) Lab Monitoring:* Sample Initiation Nomogram for Target INR 2-3 Day INR Dosage Adapted from: Arch Intern Med. 1999; 159: 46-48; and Ann • Before surgery, wait at least 24 hours after the last dose of LMW heparin is administered before a spinal/epidural catheter is placed. • After surgery, when there is adequate surgical site hemostasis, for twice daily dosing, wait at least 24 hours after catheter removal before resuming therapeutic-dose LMW heparin. ● LMW heparin – We discontinue LMW heparin 24 hours before the planned surgery or procedure, based on a biologic half-life of most subcutaneous LMW heparins of approximately three to five hours [ 7,58,62 ]. Enoxaparin Start apixaban at the time the next dose of enoxaparin was to be administered. Fondaparinux Start apixaban 24 hours after the last dose of fondaparinux. Dabigatran Start apixaban 12 hours after the last dose of dabigatran. Rivaroxaban Start apixaban 12-24 hours after the last dose of rivaroxaban. a a 2 scores, conditions that may increase baseline risks of thromboembolism), starting apixaban as early as 12 hours after the last dose of rivaroxaban may be considered. Converting from Apixaban to Anticoagulants other than Warfarin Agent Conversion Instructions Heparin Begin heparin 12 hours after the last administered dose of apixaban Enoxaparin Start enoxaparin 12 hours after the last dose of apixaban. Fondaparinux Start fondaparinux 12 hours after the last dose of apixaban. Rivaroxaban Start apixaban 12-24 hours after the last dose of rivaroxaban. a a 2 scores, conditions that may increase baseline risks of thromboembolism), starting apixaban as early as 12 hours after the last dose of rivaroxaban may be considered. Give 25-50 mg protamine IV over 10 mins, then remaining dose via continuous infusion over 8-16 hrs. Maximum rate 5 mg/min. Time Since Heparin Given Dose of Protamine per 100 units of Heparin in Patient Enoxaparin Excess: 1 mg protamine for each1 mg of enoxaparin given within the last 4 hours. If aPTT prolonged 2-4 hours after first dose, consider additional 0.5 mg protamine for each mg enoxaparin. Monitor and repeat as needed. WARFARIN (Coumadin ® , Jantoven ®) Lab Monitoring:* Sample Initiation Nomogram for Target INR 2-3 Day INR Dosage Adapted from: Arch Intern Med. 1999; 159: 46-48; and Ann At my facility if a patient is on a heparin drip, the 1st dose of lovenox is given while the drip is still running and then the drip is turned off 2 hours later. At least that's how we did it with my last patient who was on a heparin drip. # 1 5. DVT/PE? Heparin is started for immediate anticoagulation and if the patient will need to be on long term anticoagulation, lovenox can be used (usually it's one dose) before the heparin is discontinued and coumadin is started, and the until therapetic PT/INR is achieved.
http://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants http://www.anesth.utmb.edu/ASRA.htm http://www.clevelandclinicmeded.com/medicalpubs/ccjm/September2006/grant.htm http://www.downstatesurgery.org/files/forms/medical_anticoagulation.pdf http://www.uptodate.com/contents/perioperative-management-of-patients-receiving-anticoagulants http://professionalsblog.clotconnect.org/wp-content/uploads/2013/02/Apixaban-UNC-2-2013.pdf http://professionalsblog.clotconnect.org/wp-content/uploads/2013/02/Apixaban-UNC-2-2013.pdf http://www.downstatesurgery.org/files/forms/medical_anticoagulation.pdf http://allnurses.com/general-nursing-discussion/lovenox-while-on-660981.html
how long to wait after stopping heparin to start lovenox