Regional anaesthesia in patients at risk of bleeding

Abstract

Learning objectives By reading this article, you should be able to: Outline the risk of neuraxial and peripheral nerve blocks in a patient who is anticoagulated. Specify the classes of anticoagulant drugs, their key mechanisms of action and the available reversal agents. Explain which patient groups are at especially high risk of vertebral canal haematoma. Discuss principles guiding risk/benefit decisions before performing peripheral nerve blocks in patients who are anticoagulated. Regional anaesthesia is associated with a decreased rate of complications, reduced length of stay and decreased odds of ICU admission compared with GA alone in patients undergoing major truncal and lower limb surgery. 1 Central neuraxial block (CNB) may also improve perioperative outcomes after total hip and total knee arthroplasty. 2 Patients most likely to benefit from regional anaesthesia are often taking medications that increase the propensity for bleeding. Vertebral canal haematoma (VCH) is a potentially catastrophic complication of neuraxial anaesthesia. If not diagnosed and treated within 8e12 h, paraplegia is likely. 3 Whilst permanent neurological complications following peripheral nerve blocks (PNBs) are rare, seriously disabling consequences for a patient are still possible. 4 Estimates of the incidence of VCH vary substantially in the literature. Nevertheless, three large retrospective studies in Sweden (1.7 million CNB), the UK (700,000 CNB) and Finland (1.4 million CNB) indicate that this is a rare complication. 5e7 The Swedish study found that the incidence of VCH varied substantially by patient population: one in 200,000 in women undergoing obstetric epidural or combined spinaleepidural (CSE), but one in 3,600 females (and one in 9,000 males) undergoing knee arthroplasty under epidural or CSE. 5 The UK 3rd National Audit Project of the Royal College of Anaesthetists found an overall incidence of VCH of one in 117,000 for all CNBs (perioperative, obstetric, chronic pain and paediatric perioperative), but the incidence of VCH following perioperative epidural (excluding spinal anaesthesia and obstetric, paediatric and pain epidurals) was one in 16,321. 6 Similarly, the Finnish study found incidences of VCH haematoma of one in 775,000 following spinal anaesthesia, one in 26,400 for Toby Ashken FRCA is a specialty registrar at the Chelsea and Westminster Hospital, an honorary clinical teaching fellow at University College London and trainee representative for Regional Anaesthesia UK. Simeon West FRCA is a consultant anaesthetist at University College London Hospitals NHS Foundation Trust, honorary senior research associate in medical physics and bioengineering and a board member of Regional Anaesthesia UK.

Effects of Anesthetic Techniques on the Risk of Postoperative Complications Following Lower Extremity Amputation in Diabetes Patients with Coagulation Abnormalities: A Retrospective Cohort Study Using Propensity Score Analysis

“…In addition, there are concerns about nerve injury with increased nerve stimulation threshold and increased possibility of neurotoxicity due to the double crush effect, particularly in patients with diabetic neuropathy [ 23 ]. Moreover, the guidelines for performing superficial PNB in patients with coagulopathy are not well established or inconsistent [ 33 ]. Despite expecting the risk of bleeding complications following superficial lower-limb PNB to be low or intermediate [ 34 , 35 ], there are no prospective studies to validate the safety of superficial PNB in patients with coagulopathy.…”

Regional anesthesia and anticoagulation: a narrative review of current considerations

“…ASRA recommends the application of neuraxial guidelines to patients undergoing perineuraxial, deep plexus, or deep peripheral blocks 1 . For all other peripheral techniques, management should be guided by clinical judgment regarding site compressibility and vascularity and the consequences of bleeding should it occur 1,31 . The guidelines do not comprehensively stratify peripheral blocks by the associated risk of hemorrhagic complications, but they do summarize case reports that suggest that lumbar sympathetic, lumbar plexus, and proximal sciatic blocks in the presence of antithrombotic therapy may be associated with additional major morbidity 1 …”

Regional anaesthesia in patients on antithrombotic drugs – a joint ESAIC/ESRA guideline: Endorsement by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

“…A rare but feared complication to regional anaesthesia is bleeding. 1 The risk of bleeding is increased in patients on antithrombotic agents, and many patients undergoing regional anaesthesia today are elderly with co-existing diseases and on antithrombotic drugs. 2 The clinical practice guideline Regional anaesthesia in patients on antithrombotic drugsa joint ESAIC/ESRA guideline provides evidence-based recommendations for providing regional anaesthesia in adult patients on antithrombotic drugs.…”

“…A rare but feared complication to regional anaesthesia is bleeding 1 . The risk of bleeding is increased in patients on antithrombotic agents, and many patients undergoing regional anaesthesia today are elderly with co‐existing diseases and on antithrombotic drugs 2 …”