What drugs are recommended for spinal anaesthesia in a patient with a history of bleeding disorders and currently on anticoagulant medication?

Drugs for Spinal Anaesthesia in Patients with Bleeding Disorders on Anticoagulants

In patients with bleeding disorders on anticoagulants, spinal anaesthesia is generally NOT RECOMMENDED until anticoagulation is appropriately discontinued and specific time intervals have elapsed, with the exact timing dependent on the specific anticoagulant used. 1

Critical Timing Requirements Before Spinal Anaesthesia

The following minimum time intervals must elapse between the last anticoagulant dose and spinal block performance 1:

Oral Anticoagulants

• Warfarin: Stop 3-5 days before procedure; verify INR ≤ 1.4 1, 2
• Rivaroxaban (prophylactic dose): Stop 18 hours before procedure 1, 2
• Rivaroxaban (treatment dose): Stop 48 hours before procedure 1, 2
• Dabigatran: Stop 48-96 hours before procedure depending on creatinine clearance:
  • CrCl > 80 mL/min: 48 hours 1, 2
  • CrCl 50-80 mL/min: 72 hours 1, 2
  • CrCl 30-50 mL/min: 96 hours 1, 2
• Apixaban (prophylactic): Stop 24-48 hours before procedure 1

Antiplatelet Agents Requiring Discontinuation

• Clopidogrel: Stop 7 days before procedure 1, 2
• Prasugrel: Stop 7 days before procedure 1, 2
• Ticagrelor: Stop 5 days before procedure 1, 2
• Tirofiban, Eptifibatide: Stop 8 hours before procedure 1
• Abciximab: Stop 48 hours before procedure 1

Antiplatelet Agents Safe to Continue

• Aspirin: No additional precautions required 1, 2
• NSAIDs: No additional precautions required 1, 2
• Dipyridamole: No additional precautions required 1

Heparins

• LMWH (prophylactic dose): Stop 12 hours before procedure 1, 2
• LMWH (treatment dose): Stop 24 hours before procedure; epidural catheter removal NOT RECOMMENDED 1, 2
• Unfractionated heparin (IV): Stop 4 hours before procedure; verify APTTR ≤ 1.4 1
• Unfractionated heparin (subcutaneous prophylactic): Stop 4-6 hours before procedure; verify APTTR ≤ 1.4 1

Thrombolytics

• All thrombolytics (alteplase, streptokinase, etc.): Stop 10 days before procedure 1, 2

Specific Requirements for Inherited Bleeding Disorders

Patients with inherited bleeding disorders require specific factor replacement to achieve safe levels before spinal anaesthesia 2, 3:

Factor Deficiencies

• Hemophilia A/B: Factor VIII/IX ≥ 50 IU/dL for mild bleeding history; ≥ 80 IU/dL for severe bleeding history 2, 3
• Factor XI deficiency: Factor XI ≥ 50 IU/dL for mild bleeding history 2, 3
• Factor XIII deficiency: Factor XIII ≥ 50 IU/dL for mild bleeding history; ≥ 80 IU/dL for severe bleeding history 2, 3
• Fibrinogen deficiency: Fibrinogen ≥ 2.0 g/L (Clauss method) for catheter insertion 2, 3

Thrombocytopenia

• Platelet count ≥ 70,000 × 10⁶/L is generally acceptable in pregnant patients without other coagulation abnormalities 2
• Platelet count < 50,000/mcL requires individual assessment and is a relative contraindication 2

Absolute Contraindications to Spinal Anaesthesia

The following conditions absolutely contraindicate spinal anaesthesia regardless of drug choice 2:

• Active major bleeding requiring > 2 units transfusion in 24 hours 2
• Disseminated intravascular coagulopathy (DIC) 2
• Recent CNS bleeding or intracranial/spinal lesions at high risk for bleeding 2

Catheter Management Timing

If an epidural catheter is placed, the timing of catheter removal is as critical as placement timing 1, 3:

• Wait 6 hours after catheter removal before restarting: clopidogrel, prasugrel, ticagrelor, rivaroxaban (prophylaxis), dabigatran, apixaban 1
• Wait 4 hours after catheter removal before restarting LMWH prophylaxis (24 hours if traumatic placement) 1
• Catheter removal NOT RECOMMENDED while on: LMWH treatment dose, clopidogrel, prasugrel, ticagrelor 1
• Verify INR ≤ 1.4 before catheter removal in patients on warfarin 1, 3

Critical Monitoring After Spinal Anaesthesia

All patients must be evaluated for straight leg raise at 4 hours from the last dose of local anesthetic, with Bromage scale documentation 4, 3:

• Inability to perform straight leg raise at 4 hours requires immediate anesthesiologist assessment 3
• Progressive neurological deficits require urgent neuroimaging for epidural hematoma, which causes irreversible damage if not evacuated within 8-12 hours 2, 3

Common Pitfalls to Avoid

• Do not assume aspirin or NSAIDs contraindicate spinal anaesthesia—these require no additional precautions 1, 2
• Do not ignore catheter removal timing—this is as critical as placement timing, particularly with anticoagulants 1, 2
• Do not proceed if traumatic placement occurs—extend LMWH prophylaxis waiting time from 4 to 24 hours 1, 2
• Do not restart newer anticoagulants (dabigatran, rivaroxaban, apixaban) until at least 6 hours after catheter removal 1

Local Anesthetic Drugs for Spinal Anaesthesia

The choice of local anesthetic drug itself does not change based on bleeding disorder or anticoagulation status—the critical issue is whether spinal anaesthesia should be performed at all given the bleeding risk 1. Standard local anesthetics (bupivacaine, lidocaine, ropivacaine) can be used once appropriate anticoagulation timing requirements are met 4.