Neuraxial
anesthesia is an established and safe procedure in perioperative
pain therapy which can help to minimize complications and to improve perioperative outcome. In patients with acquired
bleeding disorders by comorbidities or concomitant antithrombotic medication an individual decision should be made based on risks and benefits. A large number of literature references and guidelines help making a decision, for example the recently updated evidence-based guidelines of the American Society of
Regional Anesthesia and
Pain Medicine for patients receiving antithrombotic or
thrombolytic therapy. However, no explicit recommendations or guidelines exist for patients with
hemorrhagic diatheses, such as
von Willebrand disease (vWD),
hemophilia A and B and
idiopathic thrombocytopenic purpura (
ITP). Published data regarding the safety of neuraxial techniques in these patients is scarce. Neuraxial
anesthesia in patients with vWD is only acceptable when coagulation is optimized (substitution of factor concentrates or
hemostatic agents depending on the type of vWD) and monitored frequently during the procedure. The only exception might be obstetric patients with vWD type I as coagulation frequently normalizes at the end of pregnancy. In these patients neuraxial
anesthesia can often be performed without supplementation of
clotting factors.Neuraxial techniques in patients with
hemophilia A or B are usually contraindicated. The procedure may only be acceptable if serious reasons exist against
general anesthesia. Supplementation of the missing factor to normal levels and monitoring during procedure is essential if neuraxial block is performed.Patients with
ITP often present with low platelet counts. Normally, spinal or
epidural anesthesia is considered safe if the platelet count is over 80,000/µl. However, the consistently low platelet counts in
ITP seem to be less problematic than rapidly falling values due to other diseases, because this is often accompanied by platelet dysfunction or coagulopathy. In several studies neuraxial
anesthesia was successfully performed with platelet counts between 50,000 and 80,000/µl. Nevertheless, the minimum safe platelet count for neuraxial blockade remains undefined in these patients.Evidence-based recommendations for neuraxial anaesthesia in patients with
hemophilia, vWD or
ITP cannot be offered. Each patient has to be treated individually with appropriate caution. This overview is intended to assist in the decision for or against neuraxial
anesthesia in these patients, with emphasis on the pathophysiological background, blood investigations and case reports from the literature.