Practice advisory on the bleeding risks for peripheral nerve and interfascial blockade: going out on a limb

Abstract

Although rare, neuraxial hematoma, because of the catastrophic nature of bleeding into a relatively fixed and non-compressible space, is the most significant hemorrhagic complication of regional anesthesia. Efforts to define risk factors, patient management (especially in the presence of antithrombotic therapy), and other processes to facilitate diagnosis and optimize outcomes have been the focus of evidence-based guidelines. The risk of significant bleeding complications during plexus, interfascial plane, and peripheral nerve block techniques is also rare, especially in the absence of antithrombotic therapy. Nevertheless, hemorrhagic complications following the deep plexus/deep peripheral techniques (e.g., lumbar sympathetic, lumbar plexus, and paravertebral blocks), particularly in the presence of antithrombotic therapy, are often serious and a source of major patient morbidity, including death from massive bleeding. Indeed, cases of clinically relevant bleeding associated with non-neuraxial techniques often present with signs and symptoms of significant blood loss rather than neurologic deficits. In this issue, Tsui et al. present a practice advisory sponsored by the Regional Anesthesia and Acute Pain Section of the Canadian Anesthesiologists Society addressing the bleeding risks associated with plexus, peripheral, and interfascial plane blockade. The authors, all highly respected regional anesthesiologists, are to be commended for their exhaustive review of the literature and cataloguing of bleeding complications following traditional, and more recently described, regional anesthesia and acute pain analgesic techniques. Nevertheless, despite this herculean effort, there is arguably only a limited amount of new information to add to our admittedly limited knowledge base on this topic. For example, the intent of the advisory was to guide clinical decision-making for ‘‘appropriate alterations to anticoagulation regimens before specific regional anesthesia procedures,’’ but unfortunately does not assist with the less frequent, but nevertheless equally important, perioperative management of these patients, such as timing of the removal of catheters or the dosing of anticoagulant drugs. The decision to hold an anticoagulant medication with the sole intent of placing an analgesic block is not a decision an anesthesiologist should make without collaboration with a cardiologist or primary care physician. With rare exception, plexus, interfascial plane, and peripheral nerve blocks are procedures used for analgesia, not anesthesia. They are therefore elective procedures intended to decrease pain, opioid use, and opioid-related side effects. It is entirely possible that the holding of anticoagulants in certain patients may pose risks far greater than the risk of bleeding after a peripheral nerve block or choosing an alternative analgesic approach. The two most recent American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines on anesthesia in the setting of anticoagulation or thrombotic therapy specifically address the bleeding risks of plexus and peripheral blocks. In contradistinction to the Tsui et al. practice advisory, the goal of the ASRA guidelines is to help physicians determine when/whether it is safe to T. T. Horlocker, MD (&) S. L. Kopp, MD Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, USA e-mail: [email protected]