What is the contraindication for neuraxial anesthesia in a patient with a fractured (fr) femur, considering options such as sarcoidosis, malignant hyperthermia, and anticoagulation?

Contraindications for Neuraxial Anesthesia in a Patient with Femur Fracture

Among sarcoidosis, malignant hyperthermia, and anticoagulation, anticoagulation is the absolute contraindication for neuraxial anesthesia in a patient with femur fracture, as it significantly increases the risk of spinal/epidural hematoma formation.

Anticoagulation as a Contraindication

• Anticoagulation therapy is a significant contraindication for neuraxial anesthesia due to the increased risk of spinal or epidural hematoma formation, which can cause permanent neurological damage 1
• For patients on warfarin, the International Normalized Ratio (INR) should be < 1.5 for neuraxial anesthesia to be considered safe 1
• Patients taking clopidogrel or other antiplatelet medications require special consideration, as these medications inhibit platelet function and may lead to increased bleeding risk during neuraxial procedures 1
• Glycoprotein-IIb/IIIa-receptor antagonists are an absolute contraindication for neuraxial anesthesia 2

Specific Anticoagulation Guidelines

• For warfarin: INR must be ≤ 1.4 before any neuraxial procedure 3
• For rivaroxaban: Must be stopped 18 hours before procedure 3
• For dabigatran: Must be stopped 48-96 hours before procedure, depending on renal function 3
• For thrombolytics: Should be stopped 10 days before and after neuraxial procedures 3
• For aspirin: Should be withheld at least 10 days before neuraxial blockade, unless indicated for unstable angina or recent/frequent transient ischemic attacks 1, 2

Bleeding Disorders and Platelet Considerations

• A platelet count of 50–80 × 10⁹/L is a relative contraindication to neuraxial anesthesia 1
• A platelet count below 50 × 10⁹/L will normally require pre-operative platelet transfusion before neuraxial anesthesia can be performed 1
• For patients with hemophilia, factor VIII/IX activity must be ≥50 IU/dL for those with mild bleeding history, and ≥80 IU/dL for those with severe bleeding history 3, 1
• For patients with von Willebrand disease, VWF activity level should be above 50 IU/dL for neuraxial anesthesia to be considered safe 1

Sarcoidosis and Neuraxial Anesthesia

• Sarcoidosis itself is not a contraindication for neuraxial anesthesia 1
• However, caution should be exercised if there is neurological involvement of sarcoidosis, as this may complicate the procedure or interpretation of post-procedure symptoms 1

Malignant Hyperthermia and Neuraxial Anesthesia

• Malignant hyperthermia is not a contraindication for neuraxial anesthesia 1
• In fact, neuraxial anesthesia may be preferred in patients with malignant hyperthermia susceptibility to avoid triggering agents used in general anesthesia 1

Decision-Making Algorithm for Neuraxial Anesthesia in Femur Fracture Patients

1. Assess anticoagulation status:

   • If on anticoagulants, determine if they can be safely reversed or held
   • Check INR (must be < 1.5), platelet count (must be > 80 × 10⁹/L ideally)
   • Determine time since last dose of anticoagulant/antiplatelet medication 1, 3

2. If anticoagulation status is acceptable, then evaluate for other contraindications:

   • Check for signs of infection at the proposed injection site
   • Assess for increased intracranial pressure
   • Review for coagulopathy not related to medications 1

3. Consider risk-benefit ratio:

   • Benefits of neuraxial anesthesia include reduced thrombosis risk compared to general anesthesia 4
   • Risks include potential for spinal/epidural hematoma if anticoagulation status is not optimal 5, 6

Common Pitfalls and Caveats

• Failure to recognize that the combination of multiple antiplatelet or anticoagulant medications significantly increases bleeding risk 1, 5
• Not allowing sufficient time between discontinuation of anticoagulant medication and neuraxial procedure 3, 6
• Overlooking the need for continued monitoring after neuraxial anesthesia, especially in patients who resume anticoagulation therapy 7
• Not recognizing that epidural hematoma can cause irreversible neurological damage if not evacuated within 8-12 hours of symptom onset 3