Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic therapy

- Implementation Considerations

Before starting the placement of the neuraxial intervention or deep plexus/peripheral block, do the following for the safe performance of the procedure:

·     Check the regional block equipment before starting.

·     Check the anesthetic machine first thing in morning.

·     Check the airway management equipment.

·     An Anesthetic assistant should be available.

·     Emergency drugs must be instantly available.

·     Monitoring equipment should be available (ECG, NIBP, Pulse oximeter) prior to start.

·     WHO Checklist must be done.

 

Postoperative Monitoring & Clinical Red Flags:

Patients who have experienced a traumatic tap require enhanced neurological monitoring for at least 24 hours following the procedure or until the first dose of anticoagulation has been safely tolerated.

 

The 2-hour Audit:  When indicated with neuroxial block, perform a focused neurological exam every 2 hours, assessing for:

·        Motor Deficit: New or progressive lower extremity weakness (unable to perform a straight leg raise).

·        Sensory Deficit: New or worsening numbness or "heaviness" in a dermatomal distribution.

·        Back Pain: Severe, localized back pain, often described as "stabbing" or radiating to the legs.

·        Autonomic Dysfunction: New-onset urinary retention or fecal incontinence.

 

Emergency Response: If any of the above "Red Flags" are identified:

• STAT MRI: Immediate neuroimaging (MRI is the gold standard; CT Myelogram is second line).
• Neurosurgical Consult: Immediate notification of the spine or neurosurgical team for potential emergency decompression.
• Reverse Anticoagulation: If the patient has received an anticoagulant dose, initiate reversal protocols; e.g. Protamine for Heparin, Idarucizumab for Dabigatran, or prothrombin complex concentrates (PCC) for Factor Xa inhibitors.