Regional Anesthesia and Anticoagulation in Patients undergoing Cardiothoracic and Vascular Surgery

Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural anesthesia. The decision to perform spinal or epidural anesthesia or analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, though definite risk of spinal hematoma with the benefits of regional anesthesia for a specific patient. Alternative anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The patient's coagulation status should be optimized at the time the spinal or epidural needle or catheter is placed, and the level of anticoagulation must be carefully monitored during the period of epidural catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal hematoma. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention.