What are the latest American Society of Regional Anesthesia (ASRA) guidelines for managing anticoagulation in patients undergoing regional anesthesia?

Latest ASRA Guidelines for Managing Anticoagulation in Patients Undergoing Regional Anesthesia

The latest American Society of Regional Anesthesia (ASRA) guidelines recommend specific time intervals between anticoagulant administration and regional anesthesia procedures, with different waiting periods based on drug type, dosage, and procedure risk. 1

General Principles

• Regional anesthesia complications related to bleeding are extremely rare, with neuraxial hematoma incidence at approximately 0.85 per 100,000 procedures 2
• Abnormal coagulation is always a relative (not absolute) contraindication to regional anesthesia 2
• Experienced clinicians should perform regional procedures in patients with coagulation abnormalities 2
• Risk assessment should be viewed as a continuum rather than binary thresholds 2

Neuraxial Procedures and High-Risk Peripheral Nerve Blocks

Heparins

• Unfractionated heparin (UFH) subcutaneous prophylaxis: Wait 4 hours or until normal APTTR 2
• UFH intravenous treatment: Wait 4 hours or until normal APTTR 2
• Low molecular weight heparin (LMWH) prophylaxis: Wait 12 hours 2
• LMWH treatment: Wait 24 hours 2

Oral Anticoagulants

• Warfarin: Wait until INR ≤ 1.4 2
• Rivaroxaban prophylaxis: Wait 18 hours 2
• Rivaroxaban treatment: Wait 48 hours 2
• Dabigatran (varies by renal function):
  • CrCl >80 ml/min: Wait 48 hours 2
  • CrCl 50-80 ml/min: Wait 72 hours 2
  • CrCl 30-50 ml/min: Wait 96 hours 2
• Apixaban prophylaxis: Wait 24-48 hours 2

Antiplatelet Medications

• NSAIDs and aspirin: No additional precautions needed 2
• Clopidogrel: Wait 7 days 2
• Prasugrel: Wait 7 days 2
• Ticagrelor: Wait 5 days 2
• Abciximab: Wait 48 hours 2
• Tirofiban/Eptifibatide: Wait 8 hours 2

Catheter Management and Drug Administration

• Epidural catheter removal should follow the same timing guidelines as initial placement 2
• Administration of anticoagulants after block performance or catheter removal:
  • UFH prophylaxis: Wait 1 hour 2
  • UFH treatment: Wait 4 hours 2
  • LMWH prophylaxis: Wait 4 hours (consider 24 hours if traumatic) 2
  • LMWH treatment: Wait 4 hours 2
  • Direct oral anticoagulants: Wait 6 hours 2
  • Thrombolytics: Wait 10 days 2

Special Considerations

• Anti-Xa level monitoring may be useful for certain patients on LMWH, as recent evidence suggests anticoagulant activity may persist longer than previously appreciated 3
• The fifth edition of ASRA guidelines has moved from "prophylactic/therapeutic" terminology to "low dose/high dose" to better align with other guidelines 1
• For patients with renal impairment, extended waiting periods are recommended, especially for medications with renal clearance like dabigatran 2, 4

High-Risk Scenarios

• Trauma patients require assessment of potential coagulopathy before regional anesthesia 2
• In sepsis, severe liver failure, or uraemia, coagulation status should be assessed before regional procedures 2
• For obstetric patients with pre-eclampsia, platelet count should be checked immediately before neuraxial procedures if severe or fulminating 2
• Massive transfusion is associated with altered hemostasis requiring careful assessment before regional anesthesia 2

Risk Stratification

• Peripheral nerve blocks with low bleeding risk (superficial, compressible) have less stringent timing requirements than neuraxial or deep, noncompressible blocks 5
• Healthcare teams must be competent in detecting and managing potential hematomas 5
• The 2022 joint European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Regional Anaesthesia (ESRA) guidelines have been endorsed by the Scandinavian Society of Anaesthesiology and Intensive Care Medicine and provide complementary guidance 6