Avoid the technique in patients with other coagulopathies. Heparin administration should be delayed for 1 hour after needle placement. Remove the catheter 1 hour before any subsequent heparin administration or 2-4 hours after the last heparin dose. Monitor the patient postoperatively to provide early detection of motor blockade and consider use of minimal concentration of local anesthetics to enhance the early detection of a spinal hematoma. Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case.
Clinical judgment is needed.
If a decision is made to proceed, full discussion with the surgeon and careful postoperative monitoring are warranted. Currently, sufficient data and experience are not available to determine if the risk of neuraxial hematoma is increased when combining neuraxial techniques with the full anticoagulation of cardiac surgery. Prolonged therapeutic anticoagulation appears to increase risk of spinal hematoma formation, especially if combined with other anticoagulants or thrombolytics. Therefore, neuraxial blocks should be avoided in this clinical setting. Whereas, if systemic anticoagulation therapy is begun with an epidural catheter in place, it is recommended to delay catheter removal for 2-4 hours following therapy discontinuation and evaluation of coagulation status.