Is it safe to perform an erector spinae plane (ESP) block in a patient receiving therapeutic anticoagulation (e.g., warfarin, direct oral anticoagulants, low‑molecular‑weight heparin, unfractionated heparin)?

ESP Block in Anticoagulated Patients: Safety Assessment

The ESP block is generally acceptable in patients on anticoagulants because it is a superficial fascial plane block performed far from neuraxial structures and the pleura, making it substantially safer than neuraxial techniques. 1, 2

Why ESP Block is Safer Than Neuraxial Techniques

The ESP block is performed in the tissue plane between the erector spinae muscle and the transverse processes of thoracic vertebrae—a location that is anatomically distant from both the spinal cord and pleura. 3 This superficial placement minimizes the catastrophic risk of epidural hematoma that makes neuraxial blocks (epidural, spinal) contraindicated or high-risk in anticoagulated patients. 4

Key anatomical safety features:

• The injection site is superficial and compressible, allowing direct pressure if bleeding occurs 1
• No proximity to the neuraxis means epidural hematoma—which causes irreversible paralysis if not evacuated within 8-12 hours—is not a relevant risk 5, 6
• The block avoids the pleural space, eliminating pneumothorax concerns 3

Clinical Evidence in Anticoagulated Patients

A case series specifically examined ESP blocks in 5 ICU patients with significantly altered hemostasis, including:

• INR or aPTT >1.5 times normal
• Platelet counts ≤80,000/μL
• Active anticoagulation therapy

All patients achieved effective analgesia (≥70% pain reduction, 83% opioid reduction) with no neurologic or hemorrhagic complications during 5 days of surveillance. 1

Practical Approach to Anticoagulation Management

For patients on therapeutic anticoagulation:

• The ESP block can be performed without stopping anticoagulation in most cases, given its superficial nature and compressibility 1
• This contrasts sharply with neuraxial blocks, which require complete cessation of anticoagulation with specific timing windows 4

Specific anticoagulant considerations (if you choose to hold medications):

• DOACs (rivaroxaban, apixaban, edoxaban): If electing to hold, stop 1-2 days before for low-bleeding-risk procedures when CrCl >30 mL/min 4
• Dabigatran: Requires longer interruption (3-5 days depending on renal function) only if you're treating this as a moderate-risk procedure 4
• Warfarin: Can proceed if INR ≤1.4, though this threshold applies to neuraxial blocks and is overly conservative for ESP 4, 5
• LMWH prophylactic dose: Can proceed 12 hours after last dose if holding 4
• Aspirin/NSAIDs: No interruption needed 4, 5

Critical Distinction from Neuraxial Guidelines

The French Working Group on Perioperative Hemostasis strongly recommends against neuraxial techniques in patients with possible DOAC concentrations, particularly those >80 years or with renal failure. 4 However, this recommendation specifically addresses "spinal or epidural anesthesia or deep-block techniques"—the ESP block does not fall into this high-risk category because it is a superficial interfascial plane block. 1, 2

When to Exercise Additional Caution

Consider delaying or using alternative analgesia if:

• Platelet count <50,000/μL with active bleeding 4
• Recent CNS bleeding or high risk for uncontrolled hemorrhage 4
• Severe coagulopathy with INR >3.0 or multiple concurrent abnormalities requiring hematology consultation 4, 6

Post-procedure monitoring:

• Assess the injection site for hematoma formation
• Unlike neuraxial blocks, there is no need for serial neurologic exams to detect epidural hematoma 5, 6
• The superficial location allows immediate identification and management of any bleeding complications 1

Resumption of Anticoagulation After ESP Block

Because the ESP block is not a neuraxial procedure, the stringent delays required after epidural catheter removal do not apply:

• Prophylactic LMWH: Can resume 4-6 hours post-procedure 5
• Therapeutic LMWH: Can resume 4 hours post-procedure 5
• DOACs: Can resume 6 hours post-procedure 5
• Warfarin: Can resume immediately once hemostasis confirmed 5, 6

These timelines are provided for reference but are more conservative than necessary for a superficial block like the ESP. 1

Bottom Line

The ESP block should be considered a preferred regional anesthesia technique for anticoagulated patients who require thoracic analgesia, as it provides effective pain control without the prohibitive bleeding risks associated with neuraxial approaches. 1, 2 The technique's safety profile, combined with its documented efficacy even in patients with severely altered hemostasis, makes it an excellent option when neuraxial blocks are contraindicated. 1, 3