Anaes · Perioperative medicine
Anticoagulation and neuraxial / regional anaesthesia
Also known as ASRA anticoagulation guidelines · Neuraxial haematoma risk · LMWH epidural timing · DOAC regional anaesthesia · Warfarin spinal anaesthesia
Exam-pass anticoagulation timing for neuraxial and regional anaesthesia: ASRA principles for LMWH, UFH, warfarin, DOACs and antiplatelets, catheter management, haematoma recognition, and VTE vs regional trade-offs for ANZCA Final and equivalents.
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Red flags
- Spinal/epidural haematoma presents with progressive motor/sensory deficit and bowel/bladder change — emergency MRI and decompression, not 'observe overnight'.
- Therapeutic anticoagulation plus difficult neuraxial is a haematoma recipe — check timing tables and alternative plans.
- Catheter removal is as risky as insertion — re-check the anticoagulant window before pulling.
- Aspirin alone is usually acceptable for neuraxial; dual antiplatelet therapy is not casual.
- Never invent exact hours from memory in a real case — verify current ASRA/local guideline tables.
Meet the patient
A 68-year-old on enoxaparin 1 mg/kg twice a day for a recent deep-vein thrombosis needs an emergency laparotomy, and the surgeon asks for an epidural for postoperative analgesia. The last dose was four hours ago. The trainee reaches for the epidural set because the ward wants the patient mobilising.[1]
The two questions that decide the next move are the two that decide every anticoagulated neuraxial: is the dose prophylactic or therapeutic? and is the timing window safe for both placement and the later removal? Get either wrong and the price is a haematoma.[1]
References5ShowHide
- [1]Horlocker TT, Vandermeuelen E, Kopp SL, et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) Reg Anesth Pain Med, 2018.PMID 29561531
- [2]Kopp SL, Vandermeulen E, McBane RD, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition) Reg Anesth Pain Med, 2025.PMID 39880411
- [3]Cook TM, Counsell D, Wildsmith JAW; Royal College of Anaesthetists Third National Audit Project. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists Br J Anaesth, 2009.PMID 19139027
- [4]Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain Reg Anesth Pain Med, 2018.PMID 29278603
- [5]Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Reg Anesth Pain Med, 2010.PMID 20052816