Perioperative VTE prophylaxis and neuraxial anaesthesia timing

Model answer

Framing. Balance VTE prevention against neuraxial haematoma risk using ASRA principles: drug class, dose, renal function, combination therapy, last-dose-to-needle and catheter-removal-to-next-dose intervals from the current table — never from recalled numbers. New motor block after restart of LMWH with epidural in situ is suspected haematoma until proven otherwise.^[1]

VTE side. Major joint surgery needs routine pharmacological prophylaxis: ACCP prefers LMWH, suggests adding intermittent pneumatic compression during the hospital stay, and frames optimal strategy as pharmacological plus mechanical combined.^[5]

Haematoma side. The European ESA guidance concurs on table-driven intervals, treats full anticoagulation as a contraindication to regional techniques, equates catheter removal risk with insertion risk, and requires neurological monitoring through recovery and after removal.^[4]

Crisis. Suspected haematoma: stop the infusion only if needed to clarify neurology, emergency MRI without delay, spine surgical review now — time to decompression decides outcome.^[1][4]