Perioperative Management

• Decision making regarding whether enoxaparin needs to be held depends on type of surgery, renal function, and balance of bleeding versus thrombosis risk. If it is indicated, enoxaparin should be held 12-24 hours prior to minor surgical procedures and 24-48 hours prior to major surgical procedures. May need to hold longer in patients with renal insufficiency.
• For lumbar punctures, hold enoxaparin 24 hours prior. Do not use enoxaparin in patients receiving continuous epidural anesthesia. Peri-spinal hematomas and paralysis have been reported in patients having lumbar puncture while receiving enoxaparin.
• In rare cases, in patients with very high risk of thrombosis, bridging with unfractionated heparin may be required to limit the time off anticoagulation.
• Restart enoxaparin after the procedure as soon as adequate hemostasis has been established and once cleared by the surgeon or interventionalist.