What are the considerations and procedure for spinal anaesthesia in a patient with a history of bleeding disorders and current anticoagulant medication regimen?

Spinal Anaesthesia in Patients with Bleeding Disorders and Anticoagulation

In patients with bleeding disorders on anticoagulants, spinal anaesthesia carries catastrophic risk of spinal hematoma causing permanent paralysis and is absolutely contraindicated until anticoagulation is appropriately reversed and coagulation parameters are normalized. 1, 2

Understanding the Catastrophic Risk

The primary concern is spinal or epidural hematoma resulting in irreversible cord compression and permanent neurological damage if not evacuated within 8-12 hours. 2 This risk is substantially elevated when anticoagulants are administered to patients receiving neuraxial procedures, with FDA boxed warnings specifically highlighting the paralysis risk with low molecular weight heparins (LMWH), fondaparinux, and unfractionated heparin (UFH). 1

Absolute Contraindications That Must Be Ruled Out

Before considering spinal anaesthesia in any patient with bleeding history, verify absence of:

• Recent CNS bleeding or intracranial/spinal lesions at high bleeding risk 1, 2
• Major active bleeding requiring >2 units blood transfusion in 24 hours 1, 2
• Disseminated intravascular coagulopathy (DIC) 2
• Recent spinal anaesthesia/lumbar puncture (creates temporary absolute contraindication to anticoagulation) 1

Mandatory Anticoagulant Cessation Timeframes

Direct Oral Anticoagulants (DOACs)

• Rivaroxaban prophylaxis: Stop 18 hours before procedure 2
• Rivaroxaban treatment: Stop 48 hours before procedure 2
• Dabigatran: Stop 48-96 hours before procedure depending on creatinine clearance 2
• Apixaban: Stop with last dose at D-5 (5 days before) OR verify plasma concentration <30 ng/mL 3

Heparins

• LMWH prophylaxis: Stop 12 hours before procedure 2
• LMWH treatment: Stop 24 hours before procedure 2
• UFH: Use with extreme caution; must be stopped with appropriate timing 1

Antiplatelet Agents

• Clopidogrel/prasugrel: Stop 7 days before procedure 2
• Ticagrelor: Stop 5 days before procedure 2
• Thrombolytics: Stop 10 days before procedure 2

Warfarin

• Stop warfarin and verify INR ≤1.4 before spinal anaesthesia, with INR checked within 24 hours of procedure 2, 3

Coagulation Parameters Required Before Proceeding

Platelet Assessment

• Platelet count >100,000/μL: No increased risk in normal healthy patients 1, 4
• Platelet count 75,000-100,000/μL: Acceptable if stable, not decreasing, and no other risk factors present 1
• Platelet count 50,000-70,000/μL: Higher risk territory requiring individual assessment by experienced anaesthetist 1
• Platelet count <50,000/μL: Generally avoid neuraxial anaesthesia 2, 4

Inherited Bleeding Disorders - Specific Factor Levels Required

• Hemophilia A/B carriers: Factor VIII/IX ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history 2
• Factor XI deficiency: Factor XI ≥50 IU/dL for mild bleeding history 2
• Factor XIII deficiency: Factor XIII ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history 2
• Fibrinogen deficiency: Fibrinogen ≥2.0 g/L (Clauss method) for catheter insertion 2

Standard Coagulation Screen

• PT/INR, aPTT, fibrinogen must be normal before proceeding 1, 4
• Recheck immediately before procedure if coagulopathy is dynamic or rapidly evolving 1

Critical Timing Considerations

The timing of catheter removal is as critical as placement timing, particularly with anticoagulants. 2 For LMWH prophylaxis, wait 4 hours after catheter removal before restarting (24 hours if traumatic placement). 2 For rivaroxaban prophylaxis, wait 6 hours after catheter removal before restarting. 2

Risk-Benefit Analysis: Spinal vs General Anaesthesia

When weighing the catastrophic risk of spinal hematoma against alternatives, consider that general anaesthesia carries risks of hypoxemia with airway difficulties, pulmonary aspiration (especially in laboring patients with full stomach), and thromboembolic complications. 1, 4 However, these risks are generally more manageable than irreversible spinal cord injury from hematoma. 1

The estimated residual risk for permanent harm from spinal anaesthesia in appropriately selected patients is approximately 0.02 per thousand. 5

Common Pitfalls to Avoid

• Do not assume NSAIDs or aspirin 75 mg alone contraindicate spinal anaesthesia - these require no additional precautions 2
• Do not ignore combination therapy - LMWH with aspirin 75 mg requires LMWH stopped >12 hours, platelet count >75,000/μL, and normal coagulation confirmed 1
• Do not proceed if platelet count is rapidly falling even if currently adequate 1, 4
• Do not forget that traumatic needle placement extends waiting time before LMWH prophylaxis from 4 to 24 hours 2

Special Circumstances Requiring Additional Caution

Liver Failure

Assess and correct coagulopathy before spinal anaesthesia, as all coagulation factors except Factor VIII are synthesized in the liver. 2

Uremia

Assess platelet number and function; platelet function may be improved with DDAVP; consider residual anticoagulation after dialysis. 2

Major Trauma

Assess for coagulopathy precipitated by tissue trauma, shock, hemodilution, hypothermia, and acidemia before performing spinal anaesthesia. 1, 2

Sepsis

Severe sepsis creates a procoagulant state but also increases risk of epidural abscess and meningitis, requiring careful consideration. 1, 2