Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy

The actual incidence of neurological dysfunction resulting from haemorrhagic complications associated with neuraxial block is unknown. Although the incidence cited in the literature is estimated to be >1 in 150 000 epidural and <1 in 220 000 spinal anaesthetics, recent surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increases with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard unfractionated heparin or low molecular weight heparin). The decision to perform spinal or epidural anaesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy is made on an individual basis, weighing the small, although definite risk of spinal haematoma with the benefits of regional anaesthesia for a specific patient. 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 neuraxial catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal haematoma. Vigilance in monitoring is critical to allow early evaluation of neurological dysfunction and prompt intervention. An understanding of the complexity of this issue is essential to patient management.