Haemostasis-altering drugs and central neuraxial block

The purpose of this article is to review the literature concerning the use of epidural and spinal anaesthesia in patient receiving haemostasis-altering drugs, and to provide clear guidelines concerning the safe use of those anaesthetic in this category of patients.

Relevant articles identified via a medline search and recommendation issued from consensus conferences were consulted.

Bleeding in the spinal canal is a very rare occurrence which makes it difficult to conduct randomised studies. Analysis of published case reports provide insight concerning the associated risk factors that may increase the risk of spinal haematoma. Those risk factors are predominantly, anticoagulation and puncture difficulties. Although many studies are reassuring, zero events does not mean that the risk is zero. Caution is always advised because the consequences of a spinal haematoma are devastating.

Central neuraxial block should be avoided in fully anticoagulated patients. In partially anticoagulated patient, strict delays should be respected according to the pharmacology of the anticoagulants used, before institution of the central neuraxial block. Manipulation of epidural catheters should not be done unless the level of anticoagulation is low.