Selected new antithrombotic agents and neuraxial anaesthesia for major orthopaedic surgery: management strategies

We propose recommendations to reduce the risk of haemorrhagic events associated with regional anaesthesia in patients treated with newer anticoagulants after orthopaedic surgery. The risk/benefit ratio should be individualised for each patient according to the type and dose of anticoagulant, the type of regional anaesthesia and patient risk factors. Neuraxial anaesthetic management strategy can be based on the pharmacokinetic properties of specific anticoagulants, including the time required to reach maximal concentration, half-life, and dose regimen. Central neuraxial blocks should not be performed and epidural catheters should not be removed until at least two half-lives after the last injection of anticoagulant, the half-life depending on renal function. After removing a catheter or after a haemorrhagic puncture, the timing of the next anticoagulant injection should be based on the time required for an anticoagulant dose to reach maximum activity. Vigilance remains paramount during the initial days after removal of a neuraxial catheter.