Neuraxial Anesthesia and Anticoagulants

Patients undergoing major orthopaedic procedures benefit from neuraxial anesthesia, but the concurrent administration of drugs altering hemostasis increases the probability of the serious complication of neuraxial hematoma. Some antiplatelet agents, such as aspirin and nonsteroidal antiflammatory agents, seem to have a minimal risk of neuraxial bleeding and can be administered safely to patients before or soon after neuraxial anesthesia. Newer and more potent antiplatelet agents, such as thienopyridine derivatives and glycoprotein IIb-IIIa antagonists, have a greater risk of neuraxial bleeding and need to be discontinued before neuraxial anesthesia. Heparin and oral anticoagulants substantially increase the risk of neuraxial bleeding and expert panel consensus statements have been developed in an attempt to minimize this risk. These recommendations are periodically revised and regional variations exist between the recommendations in the United States and European nations.