Regional Anesthesia in the Anticoagulated Patient: Defining the Risks

Abstract

Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective-randomized study, and there is no current laboratory model. As a result, these Consensus Statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. They are based on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management; a "cook-book" approach is not appropriate. Rather, the decision to perform spinal or epidural anesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, though definite risk of spinal hematoma with the benefits of regional anesthesia for a specific patient. Alternative anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The patient's coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation must be carefully monitored during the period of epidural catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation because this appears to significantly increase the risk of spinal hematoma. It must also be remembered that identification of risk factors and establishment of guidelines will not completely eliminate the complication of spinal hematoma. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention. We must focus not only on the prevention of spinal hematoma, but also optimization of neurologic outcome.