Direct oral anticoagulant management for neuraxial anaesthesia and deep peripheral nerve blocks

Direct oral anticoagulants (DOACs) increase the risk of bleeding in patients who receive neuraxial analgesia or deep peripheral nerve blocks. When determining the perioperative management plan for patients who take DOACs undergoing neuraxial analgesia or peripheral nerve blocks, clinicians need to balance the risks of thromboembolic complications and spinal epidural haematoma. The American Society of Regional Anesthesia and Pain Management (ASRA) guidelines recommend a conservative approach with prolonged DOAC interruption and DOAC level testing in certain circumstances. In contrast, the Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) trial protocol offers a simplified, pharmacokinetics-based strategy without routine testing that can be considered by clinicians. Early findings from the PAUSE trial suggest that a shorter DOAC interruption period can offer comparable safety. The PAUSE-2 pilot trial provides additional preliminary evidence supporting the feasibility of this approach in high bleeding risk surgeries or procedures, including neuraxial anaesthesia and deep nerve blocks. The rare occurrence of spinal epidural haematoma precludes a randomised controlled trial to study the effects of anticoagulation regimens on spinal epidural haematoma risk, a disastrous complication. We discuss safety and value considerations of the ASRA and PAUSE-2 approaches to managing DOACs in patients undergoing neuraxial anaesthesia and deep peripheral nerve blocks.