A researcher’s study showed the consumption of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Several therapeutic indications can simplify perioperative and postoperative management of anticoagulation.

The general use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), and its long-term complications cause significant morbidity, mortality and healthcare costs.

The risk of VTE is particularly high in patients who undergo major orthopedic surgery, such as total knee or hip replacement surgery; therefore, these patients routinely receive anticoagulants for short-term perioperative and postoperative thromboprophylaxis.  

Whether a patient is receiving long-term anticoagulation prior to orthopedic surgery should also be considered because appropriate anticoagulant management based on the risk of thromboembolism and bleeding is crucial in these patients 

Patients undergoing elective major orthopedic surgery receive Thromboprophylaxis because of their increased risk of developing VTE. With the overall aging of the population, more patients undergoing major orthopedic surgery are likely to be receiving anticoagulation therapy for thromboembolic disorders prior to their surgical procedure.

Several direct OACs are currently approved for different therapeutic indications, including prevention of VTE after elective knee or hip replacement surgery, and their use in clinical practice has been growing. Effective management of these direct OACs and regional anesthesia is essential to avoid bleeding complications and is, therefore, a topic of crucial interest for anesthesiologists.

Thromboprophylaxis with all direct OACs may start between 1 and 24 hours after surgery, if hemostasis has been achieved, and thus should present a lower theoretical risk of bleeding or neuraxial hematoma in case of central blocks, in comparison with preoperatively initiated LMWH.

After surgery, restarting direct OACs can be delayed by up to 48 hours in cases of bleeding or a difficult neuraxial block, and protection against thromboembolic events is achieved within hours after the first dose of these agents and without the need for bridging therapy. The effect of the type of anesthesia on clinical outcomes of the direct OACs is still unclear.

Subanalysis of RE-MODEL, RE-NOVATE, and RE-MOBILIZE data suggest that, irrespective of the anesthesia used, neuraxial anesthesia was associated with a lower risk of thromboembolic events and VTE-related mortality than general anesthesia. Equally, a subanalysis of pooled RECORD data found no significant difference in the risk of venous thromboembolic events between these types of anesthesia used.

A growing body of clinical study and real-world data, particularly with rivaroxaban, suggests that neuraxial anesthesia can be undertaken in patients undergoing major orthopedic surgery without increasing the risk of compressive hematoma, if guideline recommendations are followed and bleeding risk is evaluated on an individual basis.