Avoiding epidural hematoma related paralysis

The increasing use of platelet inhibitors (clopidogrel, Plavix) because of drug eluting stents makes careful drug history taking even more important then previously to avoid placing epidural catheters or performing subdural punctures on patients who might not clot quickly if a vessel is entered.  As prevention of deep vein thrombosis is now a national patient safety goal and as fewer insurance companies compensate for the costs associated with treating post operative blood clots, expect more aggressive post operative DVT prophylactic therapy including the use of low molecular weight heparin (Lovenox).  Thus prior to discussing post operative epidural analgesia with a patient it is necessary to know the post operative DVT prophylaxis planned by the surgical service.  In general these guidelines follow the ASRA guidelines regarding conduct of regional anesthesia in the anticoagulated patients (Reg Anesth Pain Med 2003;28:172-197). The following is the position of the UPENN Anesthesia Pain Service with respect to these issues: 

            Patients receiving anticoagulants for DVT prophylaxis or antiplatelet drugs post cardiac stenting are at a small, but real, risk of epidural hematoma if epidural catheters are placed or removed.  This includes the use of low molecular weight heparin (LMWH), unfractionated heparin or antiplatelet drugs such as clopidogrel (Plavix), NSAIDs or aspirin.  In addition it appears that the risk of harm increases with dose and with duration of therapy or when more than 1 anticoagulant is used.  Consequently:

1)      Patients who are taking LMWH or clopidogrel are not candidates for post operative epidural analgesia.  There is some data to suggest that the use of low-dose once a day LMWH is safe to use in patients with an epidural.  However the dosing used in the United States is commonly moderate to high dose, or twice a day dosing, both of which are contraindications to epidural use.

2)      Patients taking clopidogrel for whom an epidural catheter is desired should be taken off the drug for 7 days prior to the planned epidural catheter placement.

3)      Patients taking LMWH for whom an epidural catheter is desired should be taken off the drug for 12 hours if on once a day dosing or 24 hours if on twice a day dosing before epidural catheter insertion.

4)   Patients in whom an epidural catheter has been placed should not be started on LMWH or clopidogrel until the epidural catheter is removed.

David S. Smith, M.D., Ph.D.