Hematoma or Hemostasis: Anticoagulants’ Influence on Anesthetic Outcomes

On This Episode:

Today we want to unravel the intricate relationship between anticoagulants and regional anesthesia. Join Garry and Terry as they navigate through the delicate balance of benefits and risks associated with these practices. We’ll dive into the world of anticoagulation reversal agents, discussing FDA-approved options such as Idarucizumab and Andexanet.

We’ll also explore the implications of anticoagulants in regional anesthesia. We’ll also make sense of guidelines provided by the American Society of Regional Anesthesia and Pain Medicine (ASRA), addressing the co-administration of antiplatelet therapies, thienopyridine drugs, and warfarin in the context of regional anesthesia.

The show also highlights the evolving perspectives on NSAIDs, COX-2 inhibitors, and aspirin, emphasizing recent data that challenges initial concerns about spinal hematomas. The murkier waters surround thienopyridine drugs like clopidogrel, prompting recommendations for discontinuation before spinal or epidural procedures. Warfarin takes the spotlight, with ASRA advising a cessation period and normalized INR levels before regional anesthesia.

So join us to navigate the complexities of anticoagulants and regional anesthesia, emphasizing the critical role guidelines play in ensuring patient safety in the ever-evolving landscape of anesthetic practices.


Here’s some of what we discuss in this episode:

  • The evolving perspectives on NSAIDs, COX-2 inhibitors, and aspirin, emphasizing recent data that challenges initial concerns about spinal hematomas.
  • Neuraxial anesthesia, celebrated for positive outcomes, brings its own set of risks, notably bleeding and hematoma formation.
  • Heparin administration, both subcutaneous and intraoperative, prompts nuanced considerations, ensuring safety in the neuraxial procedure.
  • Insights into thrombolytic therapy, urging caution due to limited clinical data.



Charlesworth, M., T. Hayes, and G. Erdoes. “Reversal Agents for the Management of Direct Oral Anticoagulant-Related Bleeding in Cardiac Surgical Patients: The Emperor’s New Clothes?” Journal of cardiothoracic and vascular anesthesia 35.8 (2021): 2480–2482. Web.

Erdoes, Gabor et al. “Perioperative Considerations in Management of the Severely Bleeding Coagulopathic Patient.” Anesthesiology (Philadelphia) 138.5 (2023): 535–560. Web.

Hart, Brendon M. et al. “New Anticoagulants, Reversal Agents, and Clinical Considerations for Perioperative Practice.” Best practice & research. Clinical anaesthesiology 32.2 (2018): 165–178. Web.

Hofer, Stefan et al. “Management of Coagulopathy in Bleeding Patients.” Journal of clinical medicine11.1 (2021): 1-. Web.

Horlocker, Terese T et al. “Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition).” Regional anesthesia and pain medicine 43.3 (2018): 263–309. Web.

Hormese, Mary et al. “Comparison of High- and Low-Dose 4-Factor Prothrombin Complex Concentrate for the Emergent Reversal of Oral Factor Xa Inhibitors.” Journal of thrombosis and thrombolysis 52.3 (2021): 828–835. Web.

Kietaibl, Sibylle et al. “Regional Anaesthesia in Patients on Antithrombotic Drugs: Joint ESAIC/ESRA Guidelines.” European journal of anaesthesiology 39.2 (2022): 100–132. Web.

Leitch, Jordan, and Janet van Vlymen. “Managing the Perioperative Patient on Direct Oral Anticoagulants.” Canadian journal of anesthesia 64.6 (2017): 656–672. Web.

Meltzer, Joseph, and Joseph R. Guenzer. “Anticoagulant Reversal and Anesthetic Considerations.” Anesthesiology clinics 35.2 (2017): 191–205. Web.

Navas-Blanco, Jose R, Adriana Martini, and nd Fabbro. “Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians.” Journal of cardiothoracic and vascular anesthesia (2021): n. pag. Web.

Pavoni, Vittorio et al. “‘In Less than No Time’: Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy.” Journal of clinical medicine 11.5 (2022): 1407-. Web.

Rogers, Kelly C, Melanie P Shelton, and Shannon W Finks. “Reversal Agents for Direct Oral Anticoagulants: Understanding New and Upcoming Options.” Cardiology in review 24.6 (2016): 310–315. Web.

Sperry, Jeffrey D. et al. “Emergent Reversal of Antithrombotics and Treatment of Life-Threatening Bleeding from Coagulopathies: A Clinical Review.” The Journal of emergency medicine 63.1 (2022): 17–48. Web.

Wallisch, William John et al. “Coagulopathy and Emergent Reversal of Anticoagulation.” Anesthesiology clinics 41.1 (2023): 249–261. Web.


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J. Cross CRNA
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This podcast is very well put together. I love the hosts Sharon & Jeremy, they do a fantastic job at presenting topics as well as getting great speakers on the show! This is my morning commute podcast everyday! Thank you for all that you do!
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I appreciate hearing the latest and greatest in the world of Nurse Anesthesiology while also getting Class B credits. Just listen on your commute for a win/win experience. I love the perspectives from Jeremy and Sharon who both ask varied and insightful questions!
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If you’re a CRNA or any medical professional, I highly recommend giving this podcast a listen. Hosts have a great rapport.