Anaes · Regional / perioperative medicine
Perioperative VTE prophylaxis and neuraxial anaesthesia timing
Also known as perioperative vte prophylaxis neuraxial
Exam-exhaustive VTE prophylaxis versus neuraxial haematoma risk: Caprini/Padua-type risk, mechanical and pharmacological methods, ASRA principles for drug-specific timing, catheter removal rules, combination therapy, and emergency haematoma pathway for ANZCA Final.
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Red flags
- Spinal/epidural haematoma is rare but catastrophic — follow ASRA drug-specific timing tables; do not invent intervals from memory.
- Combination antithrombotics raise haematoma risk more than single agents.
- Traumatic neuraxial puncture may require delaying restart of anticoagulants — document and escalate.
- Mechanical prophylaxis alone is insufficient for many high Caprini-risk orthopaedic patients.
Meet the patient
A 68-year-old woman on rivaroxaban 20 mg daily for atrial fibrillation wants a spinal for an elective total knee replacement. Her eGFR is 40, her last dose was 24 hours ago, and the list starts in an hour. The question is not whether to give a spinal — it is whether the anticoagulation window is safe, and what you do when it is not.[1]
Two truths sit in tension, and the fellowship examiner wants to see you hold both. Omit prophylaxis and high-risk arthroplasty patients clot; ignore ASRA-type timing and a patient may be permanently paraplegic. The discriminating skill is principles and table use, not reckless recitation of hours for every drug from imperfect memory.[1]
References5ShowHide
- [1]Horlocker TT 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]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [3]Neal JM et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017 Reg Anesth Pain Med, 2018.PMID 29356773
- [4]Gogarten W et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol, 2010.PMID 20890208
- [5]Falck-Ytter Y et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012.PMID 22315265