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DAPT and Neuraxial Block — FRCA Final MCQ

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ModerateRegional AnaesthesiaDAPT and Neuraxial BlockFRCA Final

A 48-year-old man (ASA II) is scheduled for a left thoracotomy and lobectomy. A coronary stent was inserted 4 months ago, and he is taking aspirin 75 mg and clopidogrel 75 mg daily. Following cardiology review, clopidogrel must not be interrupted perioperatively. What is the most appropriate implication for planned thoracic epidural analgesia?

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Correct answer: D — Avoid thoracic epidural placement while clopidogrel continues

Clopidogrel irreversibly inhibits platelet P2Y12 receptors, impairing aggregation for the lifespan of affected platelets. Current European guidance requires a 5–7-day interval between stopping clopidogrel and neuraxial needle placement; the UK SmPC advises 7 days before elective surgery when its antiplatelet effect is undesirable. Because cardiology has stated that clopidogrel cannot be interrupted, a thoracic epidural should not be placed owing to the risk of spinal epidural haematoma in a non-compressible space. Low-dose aspirin alone does not require interruption for neuraxial blockade, but this does not negate the clopidogrel risk. Three days is insufficient. Ticagrelor is not the only problematic P2Y12 inhibitor. A thoracic paravertebral block is also a deep, non-compressible technique with bleeding risk and is not automatically a safe workaround during uninterrupted clopidogrel therapy.

Reference: Kietaibl S et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. European Journal of Anaesthesiology. 2022;39:100–132. https://pubmed.ncbi.nlm.nih.gov/34980845/