Managing Neuraxial Anaesthesia in Patients Undergoing Anticoagulation Therapy: A Narrative Review

Neuraxial anaesthesia in patients taking antithrombotic medications, including anticoagulants and antiplatelet agents, poses considerable challenges due to the increased risk of bleeding complications such as spinal or epidural haematomas. The use of both conventional anticoagulants like warfarin and newer drugs like Direct Oral Anticoagulants (DOACs) has made the decisionmaking process for anaesthesiologists more complex because these drugs affect the coagulation system differently. This review covers the mechanisms of action of antiplatelet and anticoagulant medications, and their impact on bleeding risk and complications during neuraxial anaesthesia. Preoperative considerations of relevance, e.g., drug cessation timing and coagulation monitoring, also receive mention as key to avoiding patient harm. Bleeding risks are minimised with appropriate drug regimen adjustment, selective anaesthetic practice, and case-by-case assessment of patients, all of which are discussed here. The review examines the influence of antithrombotic therapy on anaesthetic practice. It emphasises the necessity of meticulous planning to weigh the advantages of neuraxial anaesthesia against the risk of poor outcomes. In spite of the availability of some guidelines, there are a lot of controversies in the management of patients on dual or multiple antithrombotic therapy, particularly in light of the recent trend of the usage of novel anticoagulants. The review brings into focus the need for further studies to formulate evidence-based guidelines to perform neuraxial anaesthesia safely in such patients. Ultimately, better comprehension of the coagulation management, testing, and safety profile of such therapies will come to bear as improved outcomes and more precise clinical practice guidelines in this high-risk population.