Thromboprophylaxis, coagulation disorders, and regional anaesthesia

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Abstract
The surgery and trauma-induced modulation of the coagulation system includes a considerable risk of perioperative thromboembolic complications unless effective thromboprophylactic treatment is given. In the present survey the patient at risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is characterized and the documented efficacy of different currently used thromboprophylactic regimens is summarized. Systemic thromboprophylactic treatment may include a risk of an increased bleeding tendency which may lead to haemorrhagic complications. In patients with a coagulation abnormality or in patients receiving anticoagulants for perioperative thromboprophylaxis there is a fear among anaesthesiologists that the use of regional anaesthesia (spinal or epidural) may be associated with spinal haemorrhagic complications, i.e. with spinal haematoma formation leading to compression of the spinal cord and severe neurologic sequelae. Present aspects on the risk of spinal haematoma formation at the combined use of pharmacological thromboprophylactic regimens and spinal or epidural anaesthesia/ analgesia are therefore summarized. Pregnancy is associated with changes in the haemostatic system, which in the preeclamptic or eclamptic patient may be rather pronounced and constitute a clinical problem since regional anaesthetic techniques are often preferred for obstetric anaesthesia/analgesia. The specific problems to be considered prior to the choice of regional anaesthesia/analgesia for a parturient with a suspected coagulation disorder are therefore commented on in more detail. Finally, recommendations are given for safe spinal and epidural analgesic and anaesthetic routines in patients with potential haemostatic disturbances due to thromboprophylactic treatment with anticoagulants or bleeding disorders.