Haykaz Muradyan Shares Updated ESAIC/ESRA Guidance
Haykaz Muradyan, Head of the Department of Anaesthesiology and Intensive Care at Arzni Aesthetica Surgicenter, shared a post on LinkedIn:
“Regional Anaesthesia and Antithrombotic Therapy — Updated ESAIC/ESRA Guidance
Managing regional anaesthesia in patients taking antiplatelet or anticoagulant medications remains one of the most delicate balance points in modern anesthesia. The updated ESAIC/ESRA guidelines (“Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA Guidelines”) provide a comprehensive, evidence-based framework to reduce the risk of bleeding complications—especially neuraxial and deep peripheral block–related hematomas.
Key Takeaways from the 2022 ESAIC/ESRA Joint Guidelines:
1. Timing Is Critical
Strict time intervals must be respected before and after neuraxial or deep peripheral nerve blocks.
These intervals depend on:
- Drug class (VKA, DOACs, LMWH, UFH, antiplatelets)
- Dose (low vs high)
- Renal function
- Whether puncture was traumatic
- Need for catheter insertion/removal
- Superficial blocks, however, do not require withholding antithrombotic therapy.
2. Deep vs Superficial Blocks
- Deep blocks = follow neuraxial rules due to high bleeding risk.
- Superficial blocks = generally safe without stopping anticoagulants.
3. Lab Testing Helps in High-Risk Cases
Drug-level assays (anti-Xa, thrombin time, DOAC levels, INR) can guide safer timing—especially in renal impairment or when exact timing is uncertain.
4. Reversal Agents Have a Role
In emergencies:
- VKA reversal → PCC + vitamin K
- Dabigatran reversal → Idarucizumab
- Other agents (andexanet alfa, PCC for DOACs) do not change timing recommendations.
5. Ultrasound Guidance Is Strongly Recommended
Ultrasound reduces vascular puncture and increases safety—especially in anticoagulated patients.
6. Post-Block Vigilance Is Essential
All patients undergoing neuraxial/deep blocks while on antithrombotics require:
- Regular neurological checks for ≥24 hours
- Rapid imaging (MRI preferred) if deficits appear
- Urgent decompression within 6 hours if hematoma suspected
Bottom Line
Safe regional anaesthesia in anticoagulated patients demands a nuanced, individualized approach based on drug class, timing, block type, and patient-specific risk factors. These updated ESAIC/ESRA guidelines provide a clear roadmap to enhance safety, prevent catastrophic bleeding complications, and support multidisciplinary decision-making.
What do you think?
How do you approach regional anesthesia in patients on antithrombotic therapy?
Do you rely more on timing rules, lab testing, or risk stratification?
Share your insights and clinical experience in the comments ”
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