Aspirin and spinal haematoma after neuraxial anaesthesia: Myth or reality?

Abstract

The safety of aspirin therapy in neuraxial anaesthesia has been historically questioned, and the current recommendations are still heterogeneous. A comprehensive review of clinical evidence and a comparative analysis of European and American guidelines were performed. Low-dose aspirin produces a selective, complete and irreversible cyclooxygenase-1 blockade, and higher doses do not increase the antiplatelet effect. Additional cyclooxygenase-2 blockade by high-dose aspirin might decrease the antithrombotic efficacy by inhibiting endothelial prostacyclin synthesis. Different doses of aspirin have been shown to be safe in a broad population subjected to neuraxial anaesthesia or analgesia. In the few case reports of spinal haematoma involving aspirin therapy, additional complicating factors were present. Considering the available evidence, the majority of national scientific societies agree that the isolated use of aspirin does not increase the risk of spinal haematoma and does not represent a contraindication to neuraxial blocks. The precautions regarding higher doses do not seem to be justified. Although aspirin alone is considered to be safe in neuraxial anaesthesia, the concurrent administration of other antithrombotic drugs significantly increases the risk of spinal haematoma and the recommended safety times for each of these other drugs must be strictly followed. An individualized assessment of the risks and benefits should be performed, before performing a neuraxial technique or catheter removal in a patient receiving aspirin.

Spinal Epidural Hematoma Following Epidural Catheter Removal in a Patient with Postoperative Urgent Coronary Intervention and Intra-Aortic Balloon Pumping (IABP): A Case Report

“…However, low-dose isolated aspirin (acetylsalicylic acid) does not increase the risk of spinal hematoma and does not need to be stopped before neuraxial blockade [1,6]. However, this remains controversial, and there is no consensus regarding whether anti-platelet therapy should be stopped or not used during urgent PCI when the epidural catheter is removed [7]. In some case reports, following urgent PCI, the removal of an epidural catheter during anti-platelet therapy was successful when transiently discontinued with aspirin and platelet transfusion [8].…”

The assessment of platelet function using multiple electrode aggregometry in practical procedures in anaesthesia

“…A relevant problem in everyday anaesthetic practice is the lack of explicit recommendations regarding the time intervals between the final dose of antiplatelet drugs and subarachnoid or epidural anaesthesia. The suggested protocols are inconsistent [6]. In the group of patients receiving clopidogrel, a 7-day interval [7] or 5-day interval [8,9] is most commonly recommended.…”

Bloqueos de nervio periférico. ¿Cuándo no?

“…El hematoma en el sitio de punción o en las estructuras adyacentes a un catéter de nervio periférico, es una complicación que puede acarrear consigo 3 principales riesgos: necesidad de exploración quirúrgica para drenaje, transfusión y potencial daño neurológico por compresión (8) . El tratamiento con antiagregantes plaquetarios o anticoagulantes es un riesgo para la aparición de hematoma (10,11) . Si bien, el ultrasonido ha demostrado una disminución en el riesgo de punción de estructuras vasculares, en la gran mayoría de los casos reportados en la literatura con complicaciones hemorrágicas de la anestesia regional, no está informada la punción vascular accidental (7) .…”

“…Es por esto que también recomiendan diferenciar entre procedimientos de alto, intermedio y bajo riesgo de hematoma al momento de aplicar una técnica regional periférica. Por otro lado, estas guías clínicas son más específicas en señalar que las recomendaciones para la inserción y retiro de catéteres de nervio periférico deben ceñirse a aquellas vigentes para los catéteres neuroaxiales, siendo especialmente importante durante el retiro, toda vez que no existe justificación para remover un catéter durante el máximo efecto de un anticoagulante (10,12) . Las tablas 1 y 2 resumen la categorización de riesgo de cada procedimiento y las recomendaciones de tiempo de suspensión para anestesia regional periférica según estratificación de riesgo.…”