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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)
  1. Terese T. Horlocker, MD*,
  2. Denise J. Wedel, MD*,
  3. John C. Rowlingson, MD,
  4. F. Kayser Enneking, MD,
  5. Sandra L. Kopp, MD*,
  6. Honorio T. Benzon, MD§,
  7. David L. Brown, MD,
  8. John A. Heit, MD*,
  9. Michael F. Mulroy, MD,
  10. Richard W. Rosenquist, MD#,
  11. Michael Tryba, MD** and
  12. Chun-Su Yuan, MD, PhD††
  1. From the *Mayo Clinic, Rochester, MN;
  2. University of Virginia Health Science Center, Charlottesville, VA;
  3. University of Florida, Gainesville, FL;
  4. §Northwestern University, Chicago, IL;
  5. Anesthesiology Institute, Cleveland Clinic, Cleveland, OH;
  6. Virginia Mason Medical Center, Seattle, WA;
  7. #University of Iowa, Iowa City, IA;
  8. **Kassel, Germany; and
  9. ††University of Chicago, IL.
  1. Address correspondence to: Terese T. Horlocker, MD, Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905 (e-mail: horlocker.terese{at}


The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increase with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize is also consistently reported.

In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result, the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.

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