Contraindications for Neuraxial Anesthesia in Patients with Femur Fracture
Anticoagulation is an absolute contraindication for neuraxial anesthesia in patients with femur fracture due to the significant risk of spinal or epidural hematoma formation, which can cause permanent neurological damage. 1
Anticoagulation Contraindications
- Patients on warfarin with INR ≥ 1.5 should not receive neuraxial anesthesia 1
- Patients taking clopidogrel or other antiplatelet medications require special consideration due to increased bleeding risk 1
- Aspirin should be withheld at least 10 days before neuraxial blockade unless indicated for unstable angina or recent/frequent TIAs 1
- Low molecular weight heparin should be administered either 12 hours before or 12 hours after the neuraxial technique to minimize bleeding risk 2
Bleeding Disorders and Platelet Considerations
- Platelet count below 50 × 10⁹/L is an absolute contraindication and requires pre-operative platelet transfusion 1
- Platelet count between 50-80 × 10⁹/L is a relative contraindication 1
- For hemophilia patients, 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 1
- Von Willebrand disease patients should have VWF activity level above 50 IU/dL for safe neuraxial anesthesia 1
Malignant Hyperthermia Considerations
- Malignant hyperthermia (MH) is not a contraindication for neuraxial anesthesia 3
- In fact, neuraxial anesthesia is preferred in patients with MH susceptibility as it avoids triggering agents (volatile anesthetics and succinylcholine) 3
- Regional anesthesia should be considered for all patients with femur fractures unless specifically contraindicated 3
Sarcoidosis Considerations
- Sarcoidosis itself is not a contraindication for neuraxial anesthesia 3
- However, if there is neurological involvement with spinal cord compression from granulomatous lesions, neuraxial anesthesia should be avoided 3
- Careful pre-operative neurological assessment is essential in patients with sarcoidosis to rule out spinal involvement 3
Other Contraindications
- Infection at the injection site 1
- Increased intracranial pressure 1
- Patient refusal or inability to cooperate 3
- Severe hypovolemia 3
- Coagulopathy from any cause 1
Risk Mitigation Strategies
- For patients on antiplatelet therapy, platelet function testing can help determine safety for neuraxial anesthesia 4
- A functional platelet count >80 × 10⁹/L may allow for earlier surgery under neuraxial anesthesia in patients on chronic antiplatelet therapy 4
- When neuraxial anesthesia is contraindicated, peripheral nerve blocks combined with general anesthesia can be a viable alternative 5
- Femoral nerve block and lateral femoral cutaneous nerve block with general anesthesia provide more stable hemodynamics compared to lumbar and sacral plexus blocks 5
Monitoring and Safety
- Adequate neurological monitoring is essential during postoperative recovery to detect early signs of epidural hematoma 2
- Epidural hematoma can cause irreversible neurological damage if not evacuated within 8-12 hours of symptom onset 1
- The risk of complications due to bleeding increases considerably with concurrent use of multiple anticoagulant or antiplatelet medications 1
Remember that while regional anesthesia is generally preferred for patients with femur fractures 3, the final decision must be made on an individual basis after careful assessment of benefits and risks, particularly in patients with anticoagulation therapy 2.