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Clopidogrel &
epidurals
Clopidogrel &
epidurals
Dr John Zois
Epidural Haematomas
Epidural Haematomas
Rare but devastating complication of Neuraxial blocks
Irreversible Neurology if evacuation not performed within 6-12hrs post Sx Onset
Exact Risk Uknown due to rarity ?1:150,000 Epidurals ?1:220,000 Spinals
Clopidogrel Pharmacology
Clopidogrel Pharmacology
A Thienopyridine, increasingly used for prevention of vascular events in pts with established IHD
Selectively & Irreversibly blocks Platelet P2Y12 ADP Receptor -> Inhibits PLT aggregation
Max effect with 75mg dose @ 3-7/7
Bleeding time increases 2x, returns to normal @10/7
Use with aspirin for synergistic effects
ASRA Guidelines(American society of Regional anaesthesia)
ASRA Guidelines(American society of Regional anaesthesia)
Convened 2004 to form consensus on Neuraxials & Anticoagulation
Exact risk of Haematoma with antiplatelet agents is unknown
No accepted lab test to determine bleeding risk
Recommend 7/7 cessation of Clopidogrel, 14/7 of Ticlopidine
Case reportCase report
BJA-Dec 200580y F post TKR-Pt normally on clopidogrel 75mg daily. Ceased 7/7 prior to surgery. -Deltaparin 5000SC night prior to surgery (10hrs prior) as DVT prophylaxis-Atraumatic Lumbar CSE
Case reportCase report
D0 -Complained of lumbar back pain
D1- Inadvertently administered single dose of clopidogrel
Physio noted numbness + weakness of NON operated leg and attributed to epidural analgesia
Case reportCase report
D3 -Epidural removed (48hrs post clopidogrel dose) with neurology still present. Again attributed to persistent epidural block.
Neurosurg eventually consulted but 48hr delay until transfer to MRI capable centre
Case reportCase report
MRI= T12/L1 HaematomaNeurology never recovered.
Discussion..Discussion..
VCCAMM on Epidural haematomas - Incidence higher than initially thoughtConcern over frequently delayed diagnosis
Need to increase cessation period of clopidogrel to 10/7 pre op?
Remove Epidural immediately post inadvertent antiplatelets given delayed onset of action?
