Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition).

Summary

This fifth edition provides safety-focused, evidence-based recommendations for regional and neuraxial anesthesia in patients receiving antithrombotic or thrombolytic therapy. Notable updates include adopting ‘low-dose’/‘high-dose’ terminology, conservative interruption intervals, and guidance on when drug-specific assays can inform timing of blocks and catheter management.

Key Findings

• Terminology shift to ‘low dose’ and ‘high dose’ replaces ‘prophylactic/therapeutic’ to better reflect clinical dosing contexts.
• Conservative, safety-first interruption intervals are maintained to minimize neuraxial bleeding risk in rare but catastrophic events.
• Drug-specific assays (e.g., anti-Xa, direct oral anticoagulant levels) are suggested in select scenarios to guide timing of neuraxial procedures.
• Guideline is reorganized and condensed while clearly indicating changes from prior editions.

Clinical Implications

Clinicians can align block timing and catheter management with conservative interruption intervals, stratified by low/high dose categories and complemented by drug-specific assays when available. This supports safer regional/neuraxial techniques in patients on DOACs, heparins, antiplatelets, and fibrinolytics.

Limitations

• True incidence of neuraxial hemorrhage is extremely low, limiting high-quality randomized evidence.
• Conservative intervals may delay care in certain scenarios and require local adaptation to resources and assays.

Future Directions

Prospective registries and pharmacodynamic studies to validate lab thresholds and refine safe intervals for newer agents; evaluation of outcomes with assay-guided neuraxial strategies.