Neuraxial anesthesia, encompassing spinal, epidural, and caudal blocks, is an essential technique in modern anesthesia practice, offering effective pain management for a variety of surgical procedures. However, the use of neuraxial anesthesia in patients on anticoagulants comes with significant challenges due to the increased risk of bleeding complications, particularly spinal hematoma. Understanding the intricate balance between the benefits of neuraxial anesthesia and the risks associated with their use alongside anticoagulants is crucial for safe and effective patient care.
Neuraxial anesthesia involves the administration of local anesthetics near the spinal cord, targeting the nerve roots to produce sensory and motor blockades. It is commonly used in obstetrics, orthopedic surgeries, and abdominal procedures, providing excellent analgesia and muscle relaxation. Spinal anesthesia involves a single injection of anesthetic into the subarachnoid space. Epidural anesthesia involves the administration of anesthetic into the epidural space, either through an injection or a catheter. Finally, caudal anesthesia is a form of epidural anesthesia where the anesthetic is injected into the caudal epidural space, largely used in pediatric patients 1,2.
Anticoagulants are medications that reduce the blood’s ability to clot, preventing conditions like deep vein thrombosis, pulmonary embolism, and stroke. Common anticoagulants include heparin and low molecular weight heparin, used for immediate anticoagulation in hospital settings; warfarin, an oral anticoagulant used for long-term management; and direct oral anticoagulants (DOACs), including rivaroxaban, apixaban, and dabigatran, which are increasingly popular due to their predictable pharmacokinetics 3,4. The primary concern with neuraxial anesthesia in patients taking anticoagulants is the risk of spinal or epidural hematoma, a rare but potentially devastating complication that can result in permanent neurological damage 5–7.
The American Society of Regional Anesthesia and Pain Medicine (ASRA) provides comprehensive guidelines for performing neuraxial anesthesia in patients receiving anticoagulant therapy. First, it is recommended to ensure appropriate intervals between the last dose of anticoagulant and the initiation of neuraxial block. Second, since routine coagulation tests, such as prothrombin time and activated partial thromboplastin time, may not always predict bleeding risk in patients on DOACs, clinical judgment and patient history are paramount. Third, close monitoring of neurological status post-procedure is essential. If an epidural catheter is used, removal should be timed to coincide with the trough levels of anticoagulants to minimize bleeding risk. Finally, effective communication among anesthesiologists, surgeons, and hematologists ensures a coordinated approach to managing anticoagulated patients requiring neuraxial anesthesia 8.
Each patient scenario demands individualized assessment. For example, in patients on warfarin, bridging therapy with heparin might be considered, with careful timing of neuraxial procedures relative to anticoagulant cessation and reinitiation. In addition, in the context of emergency surgery, rapid reversal of anticoagulation, possibly using agents like prothrombin complex concentrates or specific antidotes for DOACs, may be necessary to safely perform neuraxial anesthesia and surgery 9–11.
Neuraxial anesthesia in patients on anticoagulants requires meticulous planning, adherence to guidelines, and vigilant monitoring to balance the benefits of effective analgesia with the risks of bleeding complications.
References
1. Candido, K. D. & Nader, A. Caudal Anesthesia. Essentials Pain Med. 587–597 (2023). doi:10.1016/B978-0-443-06651-1.50075-7
2. Overview of neuraxial anesthesia – UpToDate. Available at: https://www.uptodate.com/contents/overview-of-neuraxial-anesthesia.
3. Umerah, C. o. & Momodu, I. I. Anticoagulation. Cardiol. Board Rev. Second Ed. 615–626 (2023). doi:10.1002/9781119814979.ch30
4. Anticoagulants (Blood Thinners): What They Do, Types and Side Effects. Available at: https://my.clevelandclinic.org/health/treatments/22288-anticoagulants.
5. Kirazli, Y., Akkoc, Y. & Kanyilmaz, S. Spinal Epidural Hematoma Associated with Oral Anticoagulation Therapy. Am. J. Phys. Med. Rehabil. (2004). doi:10.1097/01.PHM.0000107498.91919.44
6. Cooper, J., Battaglia, P. & Reiter, T. Spinal epidural hematoma in a patient on chronic anticoagulation therapy performing self-neck manipulation: A case report. Chiropr. Man. Ther. (2019). doi:10.1186/s12998-019-0264-9
7. Goyal, G., Singh, R. & Raj, K. Anticoagulant induced spontaneous spinal epidural hematoma, conservative management or surgical intervention—A dilemma? J. Acute Med. (2016). doi:10.1016/j.jacme.2016.03.006
8. Amaraneni, A., Tadi, P. & Rettew, A. C. Anticoagulation Safety. StatPearls (2023).
9. Neuraxial Anesthesia and Peripheral Nerve Blocks in Patients on Anticoagulants – NYSORA. Available at: https://www.nysora.com/topics/foundations-of-regional-anesthesia/patient-management/neuraxial-anesthesia-peripheral-nerve-blocks-patients-anticoagulants/.
10. Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication – UpToDate. Available at: https://www.uptodate.com/contents/neuraxial-anesthesia-analgesia-techniques-in-the-patient-receiving-anticoagulant-or-antiplatelet-medication.
11. Ashken, T. & West, S. Regional anaesthesia in patients at risk of bleeding. BJA Education (2021). doi:10.1016/j.bjae.2020.11.004
