Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic therapy

Hemorrhagic complications may occur after any neuraxial (spinal or epidural) or peripheral/plexus regional anesthetic technique. However, when the bleeding occurs within fixed, non-compressible, and/or concealed sites, such as the spinal canal or psoas compartment, the result may be catastrophic. The development and evolving status of standards for the prevention of perioperative venous thromboembolism (VTE), as well as the introduction of increasingly more potent antithrombotic medications, resulted in concerns regarding the heightened risk of neuraxial bleeding after neuraxial and deep plexus or deep peripheral blocks. In response to these ongoing patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA PM) has published the fifth edition on 2025 [1] after four previous sets of evidence-based recommendations for the management of regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy.

The previous European Society of Anaesthesiology (ESA) guidelines on ‘regional anesthesia and antithrombotic agents’ were published in 2010 [2]. In the same year, ASRA also published its third edition of similar guidelines [3]. The fourth edition of the ASRA guidelines in 2018 were the result of a collaboration with ESA to construct a single set of guidelines [4]. As a result, the differences were only minimal. The most recent European guidelines were a collaborative effort of both the ESAIC and the ESRA and were published in February 2022 [5].

An understanding of the complexity of this issue is essential to patient management and these guidelines cannot be applied universally to the complex scenarios that may confront clinicians. Rather, the decision to perform spinal, epidural, or deep plexus/peripheral anesthesia/analgesia, as well as the timing of catheter removal in a patient receiving antithrombotic therapy, should be made on an individual basis.

The following recommendations are aimed at providing basic guidelines to anesthetic practice for Anesthesia for Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. They are intended as a framework for reasonable and acceptable patient care and should be interpreted as such to allow for some degree of flexibility in different circumstances.