Low molecular weight heparin and neuraxial anesthesia

Spinal and epidural anesthesia/analgesia provide several advantages over systemic opioids, including superior analgesia, reduced blood loss and need for transfusion, and decreased incidence of thromboembolic complications. However, patients hospitalized for major surgery often receive an anticoagulant and/or antiplatelet medication perioperatively to prevent venous thrombosis and pulmonary embolism, although the pharmacologic agent, degree of anticoagulation desired, and duration of therapy remain controversial. These patients are often not considered candidates for spinal or epidural anesthesia/analgesia because of a theoretically greater risk of spinal hematoma. Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. The incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics. The decision to perform neuraxial blockade on these patients must be made on an individual basis, weighing the risk of spinal hematoma from needle or catheter placement against the theoretical benefits gained. Familiarity with the pharmacology of hemostasis-altering drugs, as well as case reports and clinical studies involving patients undergoing neuraxial blockade while receiving these medications will guide the clinician faced with this difficult decision.