title: The anticoagulated patient.
abstract: The expanded role for antiplatelet drugs and anticoagulant therapy has resulted in more surgical patients receiving these medications during the perioperative period. The risk of developing a spinal hematoma (epidural, subdural, or subarachnoid) remains exceedingly small in most patients despite receiving these therapies. Despite the low incidence, potentially devastating neurologic sequelae often occur in the patient who develops a spinal hematoma. Irreversible paresis/paralysis can result despite excellent emergent care. Management of the patient with an abnormal bleeding history or other hemostatic abnormality must be individualized. Each situation is unique and should be considered in its totality. Certainly, patients receiving fibrinolytic agents such as streptokinase or patients with diffuse hemorrhagic problems (eg, disseminated intravascular coagulation) should avoid regional anesthesia and spinal blocks (27,28). Other situations are often less clear and require appropriate judgments by the anesthesiology consultant as to the risk/benefit ratio. Issues that must be entered into the equation include degree of hemostatic abnormality present, surgery anticipated, what if any anticoagulation is planned postoperatively, emergent versus elective surgery, skill of the regional anesthesiologist, patient desires, and associated medical abnormalities. Clearly, it is of extreme importance that documentation be thorough and include knowledge of the associated risks and why the risks are acceptable in the particular patient. This documentation provides good medical information and can be helpful should a medicolegal issue arise. This documentation should include informed consent, which is thoroughly explained to the patient and/or family. It is unlikely that anesthesiologists will be able to develop exact numbers on the incidence of spinal hematomas because of the rarity of this event. It remains extremely important that practitioners continue to report the occurrence of such hematomas, so that information can be gleaned from their experience. The experience of practitioners with LMWH and central neuraxial block, described above, currently is providing us with important information, which may ultimately affect the way we practice. Without case reporting of this information, the knowledge would remain unobtainable.
authors.affiliation: Wake Forest University Medical Center, Winston-Salem, North Carolina, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Rauck
mesh_terms: D000767:Anesthesia, Epidural / Q000379:methods*; D000775:Anesthesia, Spinal / Q000379:methods*; D000925:Anticoagulants / Q000494:pharmacology*; D001777:Blood Coagulation / Q000502:physiology*; D006801:Humans
chemical_list: D000925:Anticoagulants