Managing anticoagulant and antiplatelet drugs in patients who are receiving neuraxial anesthesia and epidural analgesia: a practical guide for clinicians

Managing patients who are receiving anticoagulant or antiplatelet drugs and are undergoing surgery with neuraxial anesthesia, is a common and challenging clinical problem because for many of these drugs there is no reliable laboratory test to measure whether an anticoagulant or antiplatelet effect is present. In patients who are to receive neuraxial anesthesia, normalized hemostasis is required to minimize the risk for epidural hematoma. This review has three objectives: (1) to provide an overview of existing and novel antithrombotic drugs used in clinical practice, and to provide suggested management guidelines regarding the management of patients who are receiving these drugs in the perioperative period; (2) to address the practical management of patients who require withholding antithrombotic drugs before elective surgery with neuraxial anesthesia, require reversing the antithrombotic effect of these drugs before emergent or urgent surgery with neuraxial anesthesia, and are receiving postoperative continuous epidural analgesia and require resumption of antithrombotic drugs; and (3) to provide a practical approach to the management of patients who are receiving postoperative epidural analgesia and are at high risk for deep vein thrombosis, in whom coadministration of low-molecular-weight heparin for thromboprophylaxis is clinically indicated.