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Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines

Henshaw, Daryl S. MD; Turner, James D. MD; Forest, Daniel J. MD; Thompson, Garrett R. PharmD; Weller, Robert S. MD

Regional Anesthesia & Pain Medicine: July/August 2017 - Volume 42 - Issue 4 - p 432–436
doi: 10.1097/AAP.0000000000000617
Regional Anesthesia and Acute Pain: Daring Discourse

Abstract: Currently, the American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines recommend that before the performance of a neuraxial procedure a minimum of 24 hours should elapse following a treatment dose of enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily). The guidelines have since their inception also consistently recommended against the routine use of anti-Xa level monitoring for patients receiving enoxaparin. However, we noted in our clinical practice that anti-Xa levels were frequently still elevated despite patients meeting the time-based recommendation for treatment dose enoxaparin. To further investigate the possibility that residual anticoagulant activity may persist longer than 24 hours after a treatment dose of enoxaparin, we assessed anti-Xa level activity in patients presenting for elective surgery. Despite nearly universal compliance with ASRA's anticoagulation guidelines (1 sample was drawn at 23.25 hours), anti-Xa activity was found to be elevated in 11 of 19 patients. While 10 patients had an anti-Xa level within the peak prophylactic range (0.2–0.5 IU/mL), 1 patient's level was found to still be in the peak therapeutic range (0.5–1.0 IU/mL). These findings suggest that significant anticoagulant activity may persist longer than previously appreciated after the last treatment dose of enoxaparin and that the current time-based ASRA recommendation may not be conservative enough. Further research is needed to delineate the level of anti-Xa activity below which it is likely safe to proceed with a neuraxial procedure, but it may be time to reconsider the utility of anti-Xa level monitoring when it is available.

From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC.

Accepted for publication March 5, 2017.

Address correspondence to: Daryl S. Henshaw, MD, Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (e-mail: dhenshaw@wakehealth.edu).

This work was supported through departmental funding from the Department of Anesthesiology, Wake Forest University School of Medicine.

The authors declare no conflict of interest.

Copyright © 2017 by American Society of Regional Anesthesia and Pain Medicine.