Contraindications for Epidural Anesthesia

Absolute Contraindications

The American Society of Anesthesiologists recommends that recent CNS bleeding or intracranial/spinal lesions at high risk for bleeding are absolute contraindications due to catastrophic risk of epidural hematoma causing irreversible neurological damage if not evacuated within 8-12 hours 1, 3
Major active bleeding requiring more than 2 units of blood transfusion in 24 hours is an absolute contraindication for epidural anesthesia 1, 3
Disseminated intravascular coagulopathy (DIC) is incompatible with safe neuraxial blockade, according to the American Society of Regional Anesthesia and Pain Medicine 2

The American College of Chest Physicians recommends that warfarin be stopped and INR must be ≤1.4 before epidural placement or catheter removal 5, 4
Rivaroxaban prophylaxis should be stopped 18 hours before procedure; wait 6 hours after catheter removal before restarting, as suggested by the European Society of Anesthesiology 5, 4
Rivaroxaban treatment should be stopped 48 hours before procedure, according to the American Society of Regional Anesthesia and Pain Medicine 5
Dabigatran should be stopped 48-96 hours before procedure depending on creatinine clearance, as recommended by the European Society of Cardiology 5, 4
Low Molecular Weight Heparin (LMWH) prophylaxis should be stopped 12 hours before procedure; wait 4 hours after catheter removal (24 hours if traumatic placement), according to the American College of Chest Physicians 5
LMWH treatment should be stopped 24 hours before procedure; epidural catheter removal not recommended, as suggested by the American Society of Regional Anesthesia and Pain Medicine 5
Thrombolytics should be stopped 10 days before and after neuraxial procedures, according to the American Heart Association 5, 4
Clopidogrel, prasugrel should be stopped 7 days before procedure, as recommended by the American College of Cardiology 5
Ticagrelor should be stopped 5 days before procedure, according to the European Society of Cardiology 5

A platelet count ≥70,000 × 10⁶/L is generally acceptable in pregnant patients without platelet dysfunction or other coagulation abnormalities, as suggested by the American College of Obstetricians and Gynecologists 6
Thrombocytopenia <50,000/mcL or severe platelet dysfunction requires individual assessment, according to the American Society of Hematology 1, 3

Hemophilia A/B carriers require factor VIII/IX ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history, as recommended by the World Federation of Hemophilia 8, 4
Factor XI deficiency requires factor XI ≥50 IU/dL for mild bleeding history, according to the European Association for Haemophilia and Allied Disorders 8, 4
Factor XIII deficiency requires factor XIII ≥50 IU/dL for mild bleeding history; ≥80 IU/dL for severe bleeding history, as suggested by the International Society on Thrombosis and Haemostasis 8, 4
Fibrinogen deficiency requires fibrinogen ≥2.0 g/L (Clauss method) for catheter insertion; ≥1.5 g/L for catheter removal in mild bleeding history; ≥2.0 g/L for all procedures in severe bleeding history, according to the American Society of Hematology 8, 4

Clinically significant systemic sepsis remains a relative contraindication due to presumed increased incidence of epidural abscess and meningitis, as suggested by the Infectious Diseases Society of America 7, 2
Febrile patients or those with systemic signs of infection require caution and consideration of deferring the procedure if risk of hematogenous infection exists, according to the American Society of Anesthesiologists 6

Liver failure requires assessment and correction of coagulopathy before epidural placement, as all coagulation factors except Factor VIII are synthesized in the liver, according to the American Association for the Study of Liver Diseases 7, 2
Uremia requires assessment of platelet number and function before epidural; platelet function may be improved with DDAVP; consider residual anticoagulation after dialysis, as suggested by the National Kidney Foundation 7, 2

Major trauma requires assessment for coagulopathy precipitated by tissue trauma, shock, hemodilution, hypothermia, acidemia, and inflammation before performing epidural, according to the American College of Surgeons 7, 2
Massive transfusion requires assessment when hemorrhage is controlled and patient is cardiovascularly stable; coagulopathy is dynamic, as suggested by the American Society of Anesthesiologists 7, 2

Intra-uterine fetal death requires checking coagulation status before epidural due to coagulation abnormalities, according to the American College of Obstetricians and Gynecologists 7, 2
Obstetric cholestasis requires checking coagulation before epidural due to decreased vitamin K absorption, though changes occur slowly, as suggested by the American Association for the Study of Liver Diseases 7, 2

Do not assume NSAIDs or aspirin alone contraindicate epidural—these require no additional precautions for epidural placement or removal, according to the American Society of Regional Anesthesia and Pain Medicine 5
Do not ignore the timing of catheter removal—this is as critical as the timing of catheter placement, particularly with anticoagulants, as suggested by the American Society of Anesthesiologists 7, 5
Do not proceed with epidural blood patch in febrile or systemically infected patients without careful consideration, according to the Infectious Diseases Society of America 6
Traumatic epidural placement requires extending the waiting time before LMWH prophylaxis from 4 to 24 hours, as recommended by the American College of Chest Physicians 5