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Neuraxial (spinal, epidural) anesthesia in the patient receiving anticoagulant or antiplatelet medication

Author
Richard Rosenquist, MD
Section Editors
Lisa Warren, MD
Lawrence LK Leung, MD
Deputy Editor
Marianna Crowley, MD

INTRODUCTION

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".)

PROBLEM OVERVIEW

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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Literature review current through: Nov 2016. | This topic last updated: Tue Jun 07 00:00:00 GMT+00:00 2016.
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