Guidelines Coagulopathy and Regional Anaesthesia

November 2013
Regional Anaesthesia and Patients

with Abnormalities of Coagulation
Published by
The Association of Anaesthetists of Great Britain & Ireland
The Obstetric Anaesthetists Association
Regional Anaesthesia UK

This guideline was originally published in Anaesthesia. If you wish to refer to this
guideline, please use the following reference:
Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists
Association and Regional Anaesthesia UK. Regional anaesthesia and patients
with abnormalities of coagulation. Anaesthesia 2013; 68: pages 966-72. This can
be viewed online via the following URL:
http://onlinelibrary.wiley.com/doi/10.1111/anae.12359/abstract
Guidelines
Regional anaesthesia and patients with
abnormalities of coagulation
The Association of Anaesthetists of Great Britain
& Ireland
The Obstetric Anaesthetists Association
Regional Anaesthesia UK
Membership of the Working Party: W. Harrop-Grifths,
T. Cook,
1
H. Gill, D. Hill,
2
M. Ingram, M. Makris, S. Malhotra,
B. Nicholls,
3
M. Popat, H. Swales
2
and P. Wood
1 Royal College of Anaesthetists
2 Obstetric Anaesthetists Association
3 Regional Anaesthesia UK
Summary
Concise guidelines are presented that relate abnormalities of coagula-
tion, whether the result of the administration of drugs or that of path-
ological processes, to the consequent haemorrhagic risks associated
with neuraxial and peripheral nerve blocks. The advice presented is
based on published guidelines and on the known properties of anti-
coagulant drugs. Four separate Tables address risks associated with
anticoagulant drugs, neuraxial and peripheral nerve blocks, obstetric
anaesthesia and special circumstances such as trauma, sepsis and mas-
sive transfusion.
2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
The Association of Anaesthetists of Great Britain and Ireland.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial
and no modications or adaptations are made.
1
....................................................................................................
This is a consensus document produced by expert members of a Working
Party established by the Association of Anaesthetists of Great Britain &
Ireland, the Obstetric Anaesthetists Association and Regional Anaesthesia
UK. It has been seen and approved by the elected Councils/Committees of
all three organisations.
Accepted: 4 June 2013
What other statements are available on this topic?

Guidance publications on regional anaesthesia in patients taking anti-
coagulant or thromboprophylactic drugs are widely available, two
well-known guidelines having been published by the American Society
of Regional Anesthesia and Pain Medicine (ASRA) [1] or adopted by
the European Society of Regional Anaesthesia and Pain Therapy
(ESRA) [2].
Why was this guideline developed?

The available published guidance focuses on neuraxial blockade in
patients receiving drug therapy specically aimed at modifying
coagulation, but does not address non-neuraxial regional blockade or
patients with abnormalities of coagulation for other reasons. Cur-
rently available guidelines are lengthy and discursive, and do not
lend themselves to use in the acute clinical setting. The remit of the
Working Party that produced these guidelines was to create a concise
document that considered regional anaesthesia of all forms and
abnormalities of coagulation of both therapeutic and pathological
origins.
How does this statement differ from existing guidelines?

Although based on the available guidance and on published pharma-
cokinetic and pharmacodynamic data pertaining to anticoagulant
drugs, this guidance is considerably more concise.
Why does this statement differ from existing guidelines?

These guidelines were developed in order to make useful and concise
guidance available to anaesthetists in the clinical setting.
Anaesthetists are often faced with the question of whether the risks of regio-
nal anaesthetic techniques are increased when performed on patients with
2 2013 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of
Anaesthesia 2013 W. Harrop-Grifths et al. | Guidelines: patients with abnormalities of coagulation
abnormalities of coagulation and, if so, whether they are so increased that
the techniques should be modied or avoided. This is not only because the
popularity of regional anaesthesia is on the rise but also because the use of
anticoagulant drugs in the prevention of venous thromboembolism is
expanding, as is the number of different drugs in use. The serious complica-
tions of regional anaesthesia in patients without abnormalities of coagula-
tion are very rare indeed [3]. For example, in the third National Audit
Project (NAP3), the incidence of vertebral canal haematoma after neuraxial
blockade was 0.85 per 100 000 (95% CI 01.8 per 100 000). The extent to
which the risk of haemorrhagic complications is increased in patients with
abnormalities of coagulation is unquantiable, but likely to be small. The
rarity of the complications means that it is difcult to make accurate esti-
mates of the incidence of complications related to abnormalities of coagu-
lation, and therefore offering patients and clinicians advice on the basis of
hard data is not possible, and is unlikely ever to become possible. We
are therefore reliant on expert opinion, case reports, case series, cohort
studies and extrapolations from drug properties such as the time taken to
achieve peak plasma levels and the known half-lives of drugs.
Published clinical guidance in relation to the risk associated with regio-
nal anaesthesia in patients with abnormalities of coagulation is often bin-
ary. For instance, it is often said that the performance of neuraxial block in
a patient with < 75 9 10
9
.l
1
platelets is not acceptable, whereas its perfor-
mance in the presence of > 75 9 10
9
.l
1
platelets is acceptable. However,
there can be no relevant difference in risk or outcome after neuraxial
blockade in two patients, one of whom has a platelet count of 74 9 10
9
.l
1
and the other 76 9 10
9
.l
1
. Risk is a continuum that runs from normal
risk to very high risk, and this guidance seeks to emphasise this point.
This guidance must be interpreted and used after consideration of an
individual patients circumstances. None of the advice in this guidance
should be taken as being prohibitive or indicative. An abnormality of
coagulation however severe is always a relative contraindication to
the use of a regional anaesthetic technique. However, there may be cir-
cumstances in which, although the use of a regional technique for a
patient with abnormal coagulation may put the patient at signicant risk
as a result, the alternative for this patient (often a general anaesthetic)
may expose them to even greater risk. Experienced clinicians should be
involved in decisions about whether or not to perform a regional anaes-
thetic technique on a patient with abnormal coagulation, and the patient
with capacity should be given all the information he/she needs to make
an informed choice.
3
W. Harrop-Grifths et al. | Guidelines: patients with abnormalities of coagulation Anaesthesia 2013
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5
Table 2 Relative risk related to neuraxial and peripheral nerve blocks in
patients with abnormalities of coagulation.
Block category Examples of blocks in category
Higher risk Epidural with catheter
Single-shot epidural
Spinal
Paravertebral blocks Paravertebral block
Lumbar plexus block
Lumbar sympathectomy
Deep cervical plexus block
Deep blocks Coeliac plexus block
Stellate ganglion block
Proximal sciatic block (Labat, Raj, sub-gluteal)
Obturator block
Infraclavicular brachial plexus block
Vertical infraclavicular block
Supraclavicular brachial plexus block
Supercial
perivascular
blocks
Popliteal sciatic block
Femoral nerve block
Intercostal nerve blocks
Interscalene brachial plexus block
Axillary brachial plexus block
Fascial blocks Ilio-inguinal block
Ilio-hypogastric block
Transversus abdominis plane block
Fascia lata block
Supercial blocks Forearm nerve blocks
Saphenous nerve block at the knee
Nerve blocks at the ankle
Supercial cervical plexus block
Wrist block
Digital nerve block
Biers block
Normal risk Local inltration
Notes to accompany Table 2
There have only been 26 published reports of signicant haemorrhagic complications of peripheral nerve and
plexus blocks [1]. Half of these occurred in patients being given anticoagulant drugs and half in patients with
normal coagulation. Patient harm has derived from:
Spinal haematoma after accidental entry into the spinal canal during attempted paravertebral blocks as
dened in the Table.
Exsanguination.
Compression of other structures, e.g. airway obstruction, occlusion of major blood vessels or tissue ischaemia.
The one death in this series was that of a patient on clopidogrel who underwent a lumbar plexus block and
subsequently exsanguinated. The majority of the 26 cases underwent deep blocks or supercial perivascular
blocks. From these data, and from other data relating to neuraxial blocks, we have placed blocks in the order of
relative risk shown in the Table.
Catheter techniques may carry a higher risk than single-shot blocks. The risk at the time of catheter removal
is unlikely to be negligible.
Ultrasound-guided regional anaesthesia, when employed by clinicians experienced in its use, may decrease
the incidence of vascular puncture, and may therefore make procedures such as supraclavicular blocks safer in
the presence of altered coagulation.
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Table 4 Risks of regional anaesthesia in patients with abnormalities of
coagulation special circumstances.
Trauma The coagulopathy of trauma is precipitated by tissue trauma,
shock, haemodilution, hypothermia, acidaemia and
inammation. Following major trauma, it is recommended that
an assessment of potential coagulopathy be made before
performing any regional anaesthetic technique.
Sepsis Severe sepsis is associated with a procoagulant state. Guidelines
support the use of chemoprophylaxis against deep venous
thrombosis. For advice on regional anaesthesia with intercurrent
thromboprophylaxis, refer to Table 1. Septic shock may be
associated with the development of a consumptive coagulopathy.
Clinically signicant systemic sepsis remains a relative
contraindication to central neuraxial anaesthesia due to the
presumed increased incidence of epidural abscess and meningitis.
Uraemia Uraemia may lead to coagulopathy secondary to
thrombocytopenia. It is recommended that all patients with
signicant uraemia undergo assessment of platelet number and
function before regional anaesthesia. Platelet function may be
improved by the administration of DDAVP.
Patients with chronic renal impairment may be managed with
regular dialysis. The presence of residual anticoagulation after
heparin administration must be considered in patients after
dialysis, and heparin reversed if indicated. If regional
anaesthesia is performed, the safety of catheter removal must
be considered in patients likely to receive heparin during
further dialysis.
Liver failure All coagulation factors except factor VIII are synthesised in the
liver. Liver failure is associated with haemostatic abnormality,
the extent of which must be assessed before regional
anaesthetic techniques are performed. There may be
thrombocytopenia and abnormal platelet function due to
associated hypersplenism. Patients in liver failure represent a
high-risk group for general anaesthesia. When regional
anaesthesia is considered as an alternative, coagulopathy must
be assessed and corrected when indicated.
Massive transfusion Massive transfusion is associated with altered haemostasis, with
dilution and consumption of coagulation factors being the
primary causes in this pathophysiological change. In assessing
the degree of coagulopathy before regional anaesthetic techniques,
it is recognised that coagulopathy in massive transfusion is a
dynamic situation. Assessment should be made when haemorrhage
is controlled and the patient is cardiovascularly stable. An
assessment of platelet function should ideally occur in patients
who have been given platelet transfusions.
Disseminated
intravascular
coagulopathy
Disseminated intravascular coagulopathy (DIC) is the
pathological activation of coagulation mechanisms in response
to a disease process leading to a consumptive coagulopathy.
A diagnosis of DIC is incompatible with safe neuraxial
blockade. When peripheral blocks are considered, they should
be at compressible sites.
Notes to accompany Table 4
All of the conditions discussed can, in their active state, be associated with signicant
coagulopathy. When regional anaesthesia is thought to be of potential value, e.g. for post-
operative analgesia, it should be conducted with reference to the guidelines outlined in the
rest of this publication.
9
Advice is often offered that if regional anaesthesia is to be consid-
ered in a patient with a known abnormality of coagulation, an experi-
enced anaesthetist should perform the procedure. There are, of course,
no hard data to support this suggestion. However, it is advice that the
Working Party supports. It is likely that an experienced regional anaes-
thetist will need fewer attempts to gain block success, and it is likely
that the complications related to bleeding are in part related to the
number of attempts at a block. It is reasonable to ask novices to per-
form their blocks on patients at normal risk, reserving attempts in
patients at increased risk for experienced clinicians.
Guidance is offered here in the form of four Tables, each with
explanatory notes: Table 1 contains recommendations related to drugs
used to modify coagulation; Table 2 suggests the relative risk related to
the performance of neuraxial and peripheral nerve blocks in patients
with abnormalities of coagulation; Table 3 indicates relative risks related
to obstetric patients; and Table 4 describes risks of regional anaesthesia
in special circumstances.
Some readers may question the absence of a section on haematologi-
cal conditions associated with abnormalities of coagulation why do we
not mention Christmas disease or other forms of haemophilia? Most of
these diseases are the result of the absence or shortage in the body of a
particular clotting factor or group of factors. Most of the patients with
haematological diseases such as these reach surgery in the full knowledge
that they have the disease. The standard treatment of bleeding resulting
from a deciency of a clotting factor or other contributor to normal coag-
ulation when faced with surgery is the administration of that factor or
other contributor after guidance from a haematologist. Therefore, for elec-
tive surgery, the solution is almost always the performance of the regional
technique after acceptable normalisation of coagulation on the advice of a
haematologist. In the emergency situation, urgent advice should be sought
from on-call haematologists.
References
1. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiv-
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and thromboembolism prophylaxis/anticoagulation: revised recommendations of
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3. Cook TM, Counsell D, Wildsmith JAW. on behalf of the Royal College of Anaesthetists
Third National Audit Project. Major complications of central neuraxial block: report
on the Third National Audit Project of the Royal College of Anaesthetists. British
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