What are the implications of using Plavix (clopidogrel) with spinal anesthesia?

From the Guidelines

Plavix (clopidogrel) should be discontinued 5 days before spinal anesthesia due to the increased risk of spinal hematoma, as recommended by the French working group on perioperative haemostasis and the French study group on thrombosis and haemostasis 1. This antiplatelet medication inhibits platelet aggregation by irreversibly blocking the P2Y12 receptor, which significantly increases bleeding risk during neuraxial procedures. For patients on Plavix requiring spinal anesthesia, coordination between the cardiologist, anesthesiologist, and surgeon is essential to balance thrombotic and bleeding risks. Some key points to consider include:

• The risk of bleeding with spinal anesthesia in patients on clopidogrel is significant, and the procedure should be avoided if possible 1.
• If spinal anesthesia is necessary, alternative anesthetic approaches such as general anesthesia should be considered in urgent cases where Plavix cannot be stopped.
• After the procedure, Plavix can typically be resumed 24 hours following spinal anesthesia if hemostasis is adequate.
• For patients with recent coronary stent placement, the decision is more complex and requires careful risk assessment, as premature discontinuation could lead to stent thrombosis 1.
• Bridging therapy with short-acting antiplatelet agents may be considered in high-risk patients during the perioperative period. It's worth noting that the most recent and highest quality study, which is from 2018, provides the most relevant guidance on this topic 1.

From the FDA Drug Label

Avoid neuraxial blockade during clopidogrel use because of the risk of spinal hematoma When possible, discontinue clopidogrel 5 to 7 days prior to labor, delivery, or neuraxial blockade.

The use of Plavix (clopidogrel) with spinal anesthesia is associated with an increased risk of spinal hematoma. To minimize this risk, it is recommended to avoid neuraxial blockade during clopidogrel use. If possible, discontinue clopidogrel 5 to 7 days prior to labor, delivery, or neuraxial blockade 2.

From the Research

Implications of Using Plavix (Clopidogrel) with Spinal Anesthesia

• The use of clopidogrel with spinal anesthesia may increase the risk of perioperative bleeding complications, such as excessive intraoperative hemorrhage, postoperative seromas, hematomas, and wound dehiscence 3.
• It is recommended to stop clopidogrel at least 7-10 days prior to spinal surgery to minimize the risk of bleeding complications 3, 4.
• However, in some cases, it may be necessary to continue clopidogrel therapy due to the risk of coronary thrombosis, and the decision to stop or continue therapy should be made on a case-by-case basis 4.
• The risk of epidural hematoma is a concern when using clopidogrel with spinal anesthesia, and patients should be closely monitored for signs of this complication 5.
• Some studies suggest that it may be safe to resume antiplatelet agents, including clopidogrel, soon after spinal surgery, but this decision should be made with caution and careful consideration of the individual patient's risk factors 4, 5.

Management of Clopidogrel Therapy in Spinal Surgery

• The management of clopidogrel therapy in patients undergoing spinal surgery requires careful consideration of the risks and benefits of continuing or stopping therapy 4.
• Patients on clopidogrel therapy should be closely monitored for signs of bleeding complications, and the decision to stop or continue therapy should be made in consultation with the patient's cardiologist and anesthesiologist 3, 4.
• The use of epidural analgesia in patients on clopidogrel therapy may be safe, but further studies are needed to confirm this finding 6.

Risks and Benefits of Continuing Clopidogrel Therapy

• The risk of coronary thrombosis is a concern when stopping clopidogrel therapy, and this risk must be weighed against the risk of bleeding complications associated with spinal anesthesia 4.
• The benefits of continuing clopidogrel therapy, including the prevention of coronary stent obstruction, must be balanced against the risks of bleeding complications 4, 5.