What are the contraindications for epidural anesthesia?

Contraindications for Epidural Anesthesia

Epidural anesthesia is absolutely contraindicated in patients with active CNS bleeding, intracranial/spinal lesions at high bleeding risk, major active bleeding requiring >2 units transfusion in 24 hours, recent spinal anesthesia/lumbar puncture, patient refusal, clinically significant systemic sepsis, and disseminated intravascular coagulopathy. 1, 2

Absolute Contraindications

Hemorrhagic and Coagulation Disorders

• Recent CNS bleeding or intracranial/spinal lesions at high risk for bleeding are absolute contraindications due to catastrophic risk of epidural hematoma causing irreversible neurological damage if not evacuated within 8-12 hours 1, 3
• Major active bleeding requiring more than 2 units of blood transfusion in 24 hours 1
• Disseminated intravascular coagulopathy (DIC) is incompatible with safe neuraxial blockade 1

Patient-Related Factors

• Patient refusal or uncooperative patients (including those with senility, alcoholism, psychosis, or lack of cooperation) 2, 4
• Infection at the puncture site or severe generalized infection 4
• Raised intracranial pressure 4

Pregnancy-Specific

• Warfarin use during pregnancy is an absolute contraindication due to placental transfer causing fetal hemorrhage and teratogenic effects 2

Relative Contraindications Requiring Risk-Benefit Assessment

Coagulation Abnormalities and Anticoagulation

Specific anticoagulant timing requirements must be strictly followed:

• Warfarin: INR must be ≤1.4 before epidural placement or catheter removal 1, 3
• Rivaroxaban prophylaxis: Stop 18 hours before procedure; wait 6 hours after catheter removal before restarting 1, 3
• Rivaroxaban treatment: Stop 48 hours before procedure 1
• Dabigatran: Stop 48-96 hours before procedure depending on creatinine clearance (48h if CrCl >80, 72h if CrCl 50-80, 96h if CrCl 30-50) 1, 3
• LMWH prophylaxis: Stop 12 hours before procedure; wait 4 hours after catheter removal (24 hours if traumatic placement) 1
• LMWH treatment: Stop 24 hours before procedure; epidural catheter removal not recommended 1
• Thrombolytics: Stop 10 days before and after neuraxial procedures 1, 3
• Clopidogrel, prasugrel: Stop 7 days before procedure 1
• Ticagrelor: Stop 5 days before procedure 1

Platelet Disorders and Thrombocytopenia

Platelet count ≥70,000 × 10⁶/L is generally acceptable in pregnant patients without platelet dysfunction or other coagulation abnormalities 1

• Thrombocytopenia <50,000/mcL or severe platelet dysfunction (from uremia, medications, dysplastic hematopoiesis) requires individual assessment 1
• For obstetric patients with HELLP syndrome or intra-uterine fetal death, check platelet count and coagulation studies immediately before the procedure as counts can decrease rapidly 1

Inherited Bleeding Disorders

Specific factor levels required before epidural placement:

• Hemophilia A/B carriers: Factor VIII/IX ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history 1, 3
• Factor XI deficiency: Factor XI ≥50 IU/dL for mild bleeding history 1, 3
• Factor XIII deficiency: Factor XIII ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history 1, 3
• Fibrinogen deficiency: Fibrinogen ≥2.0 g/L (Clauss method) for catheter insertion; ≥1.5 g/L for catheter removal in mild bleeding history; ≥2.0 g/L for all procedures in severe bleeding history 1, 3

Infection and Sepsis

• Clinically significant systemic sepsis remains a relative contraindication due to presumed increased incidence of epidural abscess and meningitis 1
• Febrile patients or those with systemic signs of infection: Exercise caution and consider deferring if risk of hematogenous infection exists 1

Organ Dysfunction

Liver failure requires assessment and correction of coagulopathy before epidural placement, as all coagulation factors except Factor VIII are synthesized in the liver; associated thrombocytopenia and platelet dysfunction from hypersplenism must be evaluated 1

Uremia requires assessment of platelet number and function before epidural; platelet function may be improved with DDAVP; consider residual anticoagulation after dialysis 1

Trauma and Massive Transfusion

• Major trauma: Assess for coagulopathy precipitated by tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation before performing epidural 1
• Massive transfusion: Assessment should occur when hemorrhage is controlled and patient is cardiovascularly stable; coagulopathy is dynamic 1

Obstetric-Specific Conditions

• Intra-uterine fetal death: Coagulation abnormalities occur in ~3% on presentation, increasing to ~13% with abruption or uterine perforation; check coagulation status before epidural 1
• Obstetric cholestasis: Check coagulation before epidural due to decreased vitamin K absorption, though changes occur slowly 1

Common Pitfalls to Avoid

• Do not assume NSAIDs or aspirin alone contraindicate epidural—these require no additional precautions for epidural placement or removal 1
• Do not perform epidural in patients with inadequate laboratory facilities for monitoring 2
• Do not ignore the timing of catheter removal—this is as critical as the timing of catheter placement, particularly with anticoagulants 1
• Do not proceed with epidural blood patch in febrile or systemically infected patients without careful consideration 1
• Traumatic epidural placement requires extending the waiting time before LMWH prophylaxis from 4 to 24 hours 1