How many days prior to a procedure should enoxaparin (low molecular weight heparin) be held?

Enoxaparin Hold Time Prior to Procedures

Hold enoxaparin for 24 hours before most procedures, with the last dose given the morning of the day prior to surgery (Day -1) at half the total daily dose for therapeutic bridging, or 24 hours before for prophylactic dosing. 1, 2

Standard Timing for Procedure Types

Prophylactic-Dose Enoxaparin (40 mg daily)

• Hold for 24 hours before standard surgical procedures to minimize bleeding risk while maintaining adequate anticoagulation clearance 2
• The 24-hour window allows adequate clearance of anticoagulant effect while minimizing thrombotic risk 2

Therapeutic-Dose Enoxaparin (Bridging Therapy)

• Stop warfarin 5 days before surgery 1
• Start therapeutic LMWH 3 days before surgery (enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily) 1
• Give the last dose 24 hours before the procedure at half the total daily dose 1
• This timing applies to patients at high thrombotic risk requiring bridging anticoagulation 1

Special Procedure Considerations

Neuraxial Anesthesia (Spinal/Epidural)

• Hold enoxaparin for 24 hours before catheter insertion or manipulation to prevent spinal hematoma 3, 2, 4
• For prophylactic once-daily dosing: hold 10-12 hours before catheter removal 4
• For intermediate dosing: hold 24 hours before catheter removal 4
• Resume no earlier than 2 hours after catheter removal 3, 4

High-Risk Bleeding Procedures

• Hold for 48 hours before high-risk procedures including neurosurgery, complex urological surgery, and cardiovascular surgery 3
• Consider delaying resumption until 48-72 hours postoperatively 2

Low-Risk Bleeding Procedures

• Hold for 24 hours before low-risk procedures such as dental extractions and minor dermatological surgery 3
• Resume 24 hours after procedure if adequate hemostasis achieved 3

Renal Impairment Adjustments

For patients with creatinine clearance 15-29 mL/min:

• Hold for at least 36 hours before low-risk procedures 3
• Hold for 48 hours before high-risk procedures 3
• The prophylactic dose should be reduced to 30 mg daily in patients with CrCl <30 mL/min, but the 24-hour hold time remains appropriate 2

Postoperative Resumption

Standard Procedures

• Resume 12-24 hours after surgery once hemostasis is established 2
• For low-bleeding risk procedures: restart at previous dose on Day 1 1
• For high-bleeding risk procedures: wait 48-72 hours before resuming full-dose LMWH 1

After Neuraxial Anesthesia

• Resume no earlier than 2 hours after epidural catheter removal 3, 2, 4
• Low-dose LMWH (enoxaparin 40 mg daily) can be used for VTE prophylaxis for the first 24-72 hours post-procedure, with full dose resumed 2-3 days post-procedure 1

Critical Pitfalls to Avoid

Do not give enoxaparin too close to neuraxial procedures - this is the most serious complication risk, potentially causing epidural hematoma and permanent neurologic injury 3, 2, 4

For therapeutic bridging, do not give a full dose as the last pre-procedure dose - use half the total daily dose 24 hours before surgery to reduce bleeding risk while maintaining some anticoagulant effect 1

Do not resume therapeutic-dose LMWH immediately after high-bleeding risk surgery - a major bleed rate as high as 20% may occur if treatment-dose LMWH is given too close to surgery 1