Epidural anesthesia is commonly and appropriately used in patients at varying levels of VTE risk. What interventions and recommendations exist to minimize the risk of bleeding in these patients?
Neuraxial blockade has several advantages over systemic opioids, but the risk of spinal or epidural hematoma may be increased with the concomitant use of antithrombotic drugs. Therefore, these agents must be used cautiously in patients with neuraxial blockade.1 Guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA) contain the following recommendations2: • Subcutaneous UFH: No contraindication, consider delaying heparin until after block if technical difficulty is anticipated • LMWH: Twice daily dosing-LMWH 24 hours after surgery, regardless of technique; remove neuraxial catheter 2 hours before first LMWH dose • Warfarin: Document normal INR after discontinuation (prior to neuraxial technique); remove catheter when INR Of course before initiating thromboprophylaxis, it is important to evaluate the risk of bleeding, and patients should be assessed for contraindications that could increase that risk. The risk factors for spinal hematoma in neuraxial blockad
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