Undertaking Caudal Epidural in Patients on Rivaroxaban

Undertaking Caudal Epidural in Patients on Rivaroxaban

What is a Caudal Epidural?

A caudal epidural is any injection placed in the tail end of the epidural space. The epidural space is the space around the dura mater, which is a covering surrounding the central nervous system and cauda equina in the spinal canal. The treatment of pain in this area can be achieved by measures other than a caudal epidural injection. Thus, the use of this injection is an optional and temporary pain management technique best reserved for self-limiting conditions.

Risks associated with Caudal Epidural

Caudal epidural injections run the risks of infection, bleeding, nerve injury and intraspinal injection. Infection and bleeding in the spinal canal can lead to death or paralysis if epidural abscess of haematoma forms. Spinal injection can cause respiratory paralysis and require a period of ventilation.

What is Rivaroxaban?

Rivaroxaban is an anticoagulant that makes it less likely for your blood to make a dangerous clot (Reference 1). Rivaroxaban is used to treat those who are more at risk of developing a blood clot. This includes people who:

  • Have an abnormal heartbeat;
  • Have coronary heart disease;
  • Have suffered a stroke
  • Have previously suffered a blood clot in their legs or lungs.

The correlation between risks of Caudal Epidural and Rivaroxaban

The greatest risk associated with caudal epidural injection is epidural bleeding and epidural haematoma, which will also increase the risk of infection. There is a higher risk of these complications for a patient who is taking antiplatelet agents and Rivaroxaban. Higher risk is present with larger gauge needles and with interventional procedures as well if the patient has abnormal platelets or other intrinsic clotting disturbance.

Learning point

As with any form of procedure, caudal epidurals come with associated risks which must be consented to. When the patient is also on Rivaroxaban, this must be considered during the consenting process, meaning that the patient is not just informed of the general risks of this injection, but that they are at a slightly increased risk of these side effects. The risks should be explained to ensure that fully informed consent is received.

References

  • NHS. (2019). Rivaroxaban. Available: https://www.nhs.uk/medicines/rivaroxaban/. Last accessed 4th Aug 2021.
  • Co-authored by The TMLEP Clinical Risk and Patient Safety Publishing Group and Ms Georgia Millington, TMLEP Analyst and Mr Jason Bernard, Consultant Orthopaedic and Spinal Surgery. (2021). Undertaking Caudal Epidural in Patients on Rivaroxaban. TMLEP Clinical Risk Case Studies. 4 (9), 1.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact [email protected] or call +44 (0) 203 355 9796.