Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology

Background and objectives Performing neuraxial anaesthesia in patients receiving antithrombotic drugs is controversial due to the increased risk of spinal epidural haematoma. Strict adherence to the recommended time intervals between the administration of anticoagulants, neuraxial blockade and the removal of catheters is thought to improve patient safety and reduce the risk of haematoma. Appropriate guidelines have been prepared by a number of national societies of anaesthesiologists, but they do not have universal acceptance. The introduction of new anticoagulants together with recent reports of stent thrombosis in patients with perioperative cessation of antiplatelet drugs have considerably broadened the issue and made revision necessary. To overcome deficiencies in content and applicability, the European Society of Anaesthesiology has taken the initiative to provide current and comprehensive guidelines for the continent as a whole. Methods Extensive review of the literature. Results and conclusions In order to minimise bleeding complications during regional anaesthetic techniques, care should be taken to avoid traumatic puncture. If a bloody tap occurs when intraoperative anticoagulation is planned, postponing surgery should be considered. Alternatively, catheters can be placed the night before surgery. Regional anaesthesia in patients receiving full anticoagulation treatment continues to be contraindicated. Catheter manipulation and removal carry similar risks to insertion and the same criteria should apply. Appropriate neurological monitoring is essential during the postoperative recovery period and following catheter removal. The final decision to perform regional anaesthesia in patients receiving drugs that affect haemostasis has to be taken after careful assessment of individual risks and benefits. Eur J Anaesthesiol 2010;27:999-1015