Does a patient undergoing a celiac plexus block need to hold heparin (unfractionated heparin/low molecular weight heparin)?

Management of Anticoagulation for Celiac Plexus Block

Patients on heparin (unfractionated or low molecular weight) should hold anticoagulation before undergoing a celiac plexus block, with timing dependent on the specific anticoagulant type.

Anticoagulation Timing Guidelines

For Low Molecular Weight Heparin (LMWH):

• Hold LMWH for 24 hours before the procedure 1
• For prophylactic dosing: Last dose should be given at least 12 hours before the procedure
• For therapeutic dosing: Last dose should be given at least 24 hours before the procedure

For Unfractionated Heparin (UFH):

• Hold intravenous UFH for 4-6 hours before the procedure 1
• Check activated partial thromboplastin time (APTT) or activated clotting time (ACT) before proceeding

Risk Assessment and Classification

Celiac plexus blocks are considered intermediate-risk procedures for bleeding due to:

• Proximity to major vascular structures
• Deep anatomical location
• Limited ability to apply direct pressure if bleeding occurs

Evidence Supporting Recommendations

The Association of Anaesthetists of Great Britain & Ireland guidelines classify regional anesthesia procedures by bleeding risk, with celiac plexus blocks falling into an intermediate-risk category 1. These guidelines recommend specific timing intervals for holding anticoagulants before procedures.

A retrospective study of 402 celiac plexus block procedures found a low incidence (1.2%) of patients requiring red blood cell transfusion within 72 hours of the procedure 2. While this study suggested that aspirin and NSAIDs might be continued safely, it did not specifically address the safety of continuing therapeutic heparin.

Special Considerations

High Thrombotic Risk Patients:

• For patients with mechanical heart valves, recent venous thromboembolism (<3 months), or atrial fibrillation with high CHADS₂ score (≥5) 3:
  • Consider bridging with reduced doses of LMWH
  • Consult with hematology or cardiology for individualized management

Resumption of Anticoagulation:

• LMWH can typically be resumed 6-8 hours after the procedure if there are no signs of bleeding 1
• UFH can be resumed 1-2 hours after the procedure if hemostasis is adequate

Procedural Considerations

• Use imaging guidance (CT or ultrasound) to minimize the risk of vascular puncture
• Consider alternative approaches (anterior vs. posterior vs. lateral) based on patient anatomy to minimize risk 4, 5
• Monitor patients closely for at least 2 hours post-procedure for signs of bleeding or other complications

Potential Complications

• Bleeding complications are rare but can be serious due to the proximity of major vessels
• Neurologic complications can occur from bleeding near neural structures
• Pulmonary embolism has been reported as a rare complication following celiac plexus block 6

The decision to proceed with celiac plexus block in anticoagulated patients should balance the risk of bleeding against the need for pain control. When possible, following the recommended timing intervals for holding anticoagulation will minimize bleeding risk while maintaining procedural efficacy.