Do you hold aspirin (acetylsalicylic acid) prior to epidural injections according to the American Society of Regional Anesthesia (ASRA) guidelines?

Management of Aspirin Prior to Epidural Injections According to ASRA Guidelines

According to the American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines, aspirin is not a contraindication to central neuraxial anesthesia including epidural injections and should not be discontinued prior to these procedures if the benefit-risk ratio is favorable.

Evidence-Based Recommendation

The French Working Group on Perioperative Haemostasis (GIHP) and French Study Group on Thrombosis and Haemostasis (GFHT) guidelines clearly state that aspirin is not a contraindication to central neuraxial anesthesia when the benefit-risk ratio is favorable and there are no associated abnormalities of hemostasis, including concomitant anticoagulant therapy 1.

Risk Assessment for Epidural Procedures

Factors Supporting Continuation of Aspirin

• Aspirin monotherapy carries a very low risk of bleeding complications during neuraxial procedures 1
• Prospective studies have confirmed the safety of epidural procedures in patients receiving aspirin-like medications 2
• In a study of 1,214 epidural steroid injections, aspirin use did not increase the frequency of minor hemorrhagic complications 2

Factors Requiring Aspirin Discontinuation

• Presence of other anticoagulants or P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) 1
• Pre-existing platelet defects or thrombocytopenia 1
• Multiple risk factors for bleeding that could compound the risk

Procedural Considerations

When performing epidural injections in patients on aspirin:

1. Technique Optimization:

   • Single-puncture spinal anesthesia is preferable to epidural anesthesia when possible 1
   • Use ultrasound guidance when available to reduce risk of vascular puncture 1
   • Minimize the number of needle passes and insertion attempts 2

2. Monitoring:

   • Watch for signs of bleeding during needle placement
   • Monitor for new neurologic symptoms or worsening of existing complaints post-procedure 2

Important Caveats

• While aspirin can be continued, P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) must be discontinued 5-7 days before epidural procedures 1
• If an epidural catheter is placed, the same precautions apply for catheter removal as for insertion 1
• The decision to continue aspirin should consider the patient's cardiovascular risk profile and the specific indication for aspirin therapy

Special Considerations

Despite the general recommendation to continue aspirin, there are isolated case reports of epidural hematomas following interventional procedures in patients on low-dose aspirin 3. These rare events highlight the importance of:

1. Prompt recognition of symptoms suggesting epidural hematoma
2. Immediate surgical intervention if a hematoma is suspected
3. Careful risk assessment in elderly patients or those with multiple comorbidities 4

In conclusion, while some spine surgeons may recommend stopping aspirin 7-10 days before procedures 5, the current ASRA-aligned guidelines support continuing aspirin therapy during epidural injections when the cardiovascular benefits outweigh the minimal increased bleeding risk.