Neuraxial (spinal, epidural) anesthesia in the patient receiving anticoagulant or antiplatelet medication
- Richard Rosenquist, MD
Richard Rosenquist, MD
- Chairman, Pain Management Department
- Anesthesiology Institute
- Cleveland Clinic
- Section Editors
- Lisa Warren, MD
Lisa Warren, MD
- Section Editor — Regional Anesthesia
- Assistant Professor of Anesthesia
- Harvard Medical School
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
Neuraxial anesthetics are used in many settings, as intraoperative anesthetics, for postoperative pain control, in the peripartum period, and in the management of chronic pain. Patients who are candidates for neuraxial anesthesia may be on chronic antiplatelet or anticoagulation therapy, may require anticoagulation during or following surgery, or may receive prophylactic medication for venous thromboembolism in the perioperative period. These patients are at increased risk for hemorrhagic complications of neuraxial anesthesia.
This topic will discuss the level of risk, the management of antithrombotic (anticoagulant and antiplatelet) medication in conjunction with neuraxial procedures, and the timing of neuraxial intervention relative to antithrombotic medication in non-pregnant patients. Neuraxial procedures in obstetrical patients and patients being treated for chronic pain are discussed in more detail elsewhere (see "Adverse effects of neuraxial analgesia and anesthesia for obstetrics"). In-depth discussion of neuraxial anesthesia and analgesia is also found elsewhere. (See "Neuraxial analgesia for labor and delivery (including instrumented delivery)" and "Spinal anesthesia: Technique".)
Other types of nerve blocks are discussed separately. While in general the recommendations presented here are applicable to patients having paravertebral and other "deep" blocks (in anatomic locations not amenable to the application of pressure to control hemorrhage), recommendations regarding antithrombotic medication may not be as rigid for more superficial blocks; this is discussed elsewhere. (See "Overview of peripheral nerve blocks" and "Lower extremity nerve blocks: Techniques".)
Bleeding is the major complication of antithrombotic therapy. When this bleeding occurs in the closed space of the spinal canal, the expanding hematoma causes increased pressure on the spinal cord or cauda equina, which in turn may lead to spinal cord ischemia and infarction.
Following neuraxial anesthesia (spinal or epidural), bleeding is most commonly from vessels in the prominent venous plexus of the epidural space, although it can be in the subdural space. We will refer to this bleeding as spinal epidural hematoma (SEH); the considerations discussed below do not differ for other bleeding locations within the spinal canal.
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- PROBLEM OVERVIEW
- SPINAL EPIDURAL HEMATOMA (SEH)
- Incidence after neuraxial anesthesia
- Risk factors
- Typical presentation
- USE OF NEURAXIAL ANESTHESIA IN PATIENTS ON ANTITHROMBOTIC MEDICATION
- TIMING OF PLACEMENT AND REMOVAL OF SPINAL OR EPIDURAL
- Unfractionated heparin (UFH)
- - Therapeutic UFH (intravenous)
- Preoperative intravenous (IV) UFH
- IV UFH bolus during surgery
- - Traumatic neuraxial needle or catheter placement
- - Cardiac surgery
- - Prophylactic UFH (subcutaneous)
- Three-times-daily heparin dosing
- Low molecular weight heparin (LMWH)
- - Therapeutic LMWH
- Neuraxial placement after therapeutic LMWH
- Therapeutic LMWH after neuraxial placement
- Therapeutic LMWH after traumatic neuraxial placement
- Therapeutic LMWH after neuraxial catheter removal
- - LMWH thromboprophylaxis
- Neuraxial placement after prophylactic LMWH
- Prophylactic LMWH after neuraxial placement
- Prophylactic LMWH after traumatic neuraxial placement
- Neuraxial catheter removal after prophylactic LMWH
- Prophylactic LMWH after neuraxial catheter removal
- - Patients on long-term warfarin anticoagulation
- - Single warfarin dose prior to surgery
- - Warfarin dosing with indwelling neuraxial catheter
- - Removing a neuraxial catheter in a patient on warfarin
- - Dosing warfarin after neuraxial anesthesia
- Direct oral anticoagulant drugs
- - Direct factor Xa inhibitors
- - Direct thrombin inhibitors
- - Other drugs
- Antiplatelet drugs
- - Aspirin and other NSAIDs
- - P2Y12 receptor blockers
- - GPIIb/IIIa inhibitors
- - Other antiplatelet mechanisms
- - Thrombolytic agents
- - Herbal medications
- Multiple antithrombotic drugs
- PREVENTION OF NEUROLOGIC DAMAGE FROM SPINAL HEMATOMA
- Neurologic monitoring
- Evaluation, management, and prognosis
- SUMMARY AND RECOMMENDATIONS