REGIONAL ANALGESIA AND CONCURRENT ANTICOAGULANT MEDICATION


    The following advice is based on the American Society for Regional Anaesthetics and Pain Medicine consensus statement (Horlocker et al 2003). An individual risk/benefit assessment of every patient should still be conducted before embarking on neuraxial blockade.

    Aspirin and NSAIDS


    NSAIDs alone do not significantly increase the risk of spinal haematoma. Regard as a risk factor if in combination with other classes of anticoagulants.
    Clopidogrel - Ideally stop 7 days before surgery. Should not be stopped in patients with drug-eluting coronary stents. Involve consultant anaesthetist, haematologists, surgeons and cardiologists if considering neuraxial blockade.


    Unfractionated IV and SC heparin

    • Neuraxial Blockade - Wait 4 hours after last dose.

    • Catheter removal - Epidural catheters should be removed 2-4 hours after the last heparin dose and following an evaluation of the patient's coagulation status. Patients who have had more than 4 days of heparin therapy should have platelet level checked (heparin induced thrombocytopaenia possible)
    • Heparin therapy - May be started 1 hour after catheter placement


    LMWH

    • Neuraxial Blockade - Wait at least 12 hours after standard prophylactic dose. Wait 24 hours after a therapeutic dose.
    • Catheter removal - The epidural catheter should be removed at least 12 hours after the last dose of LMWH. The next dose should not be given until at least 2 hours after removal
    • LMWH therapy - May be started 6-8 hours postoperatively. The second postoperative dose should occur no sooner than 24 hours after the first dose. In case of traumatic needle or catheter insertion initiation of LMWH therapy should be delayed for 24 hours postoperatively in discussion with the surgeon. LMWH is excreted renally and effects may be prolonged in renal failure patients.


    Warfarin

    • Ideally discontinued 4-5 days prior to block
    • INR should be measured prior to neuraxial blockade and removal of epidural catheter. An INR of less than 1.5 is estimated to be safe.
    • Consider concurrent use of medications affecting other components of the clotting cascade.

    Horlocker TT. Wedel DJ. Benzon H et al Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 28:172-97