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DOAC Restart After Neuraxial — FRCA Final MCQ

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ModerateRegional AnaesthesiaDOAC Restart After NeuraxialFRCA Final

A 72-year-old woman (ASA III) is scheduled for right total hip replacement. She takes rivaroxaban 20mg daily. The surgical and anaesthetic teams agree on spinal anaesthesia. She takes her last rivaroxaban 26 hours before the scheduled spinal. The spinal is inserted uneventfully. When is the earliest time rivaroxaban can be safely recommenced after spinal catheter removal?

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Correct answer: C — 6 hours after

After neuraxial catheter removal, rivaroxaban should not be restarted for at least 6 hours. For a single-shot spinal (no catheter), rivaroxaban can be restarted 6 hours after the procedure. These intervals are based on the time needed for haemostatic plug formation at the puncture site in the epidural venous plexus. Starting DOAC too early after neuraxial procedures increases the risk of epidural haematoma. The interval is shorter than for insertion (24 hours) because the risk of haematoma from a needle puncture decreases rapidly once the procedure is complete.

Reference: Association of Anaesthetists – 2013 – Regional anaesthesia and coagulation; ESA – 2022 – Perioperative anticoagulant management