SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez nos Conditions d’utilisation et notre Politique de confidentialité.
SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez notre Politique de confidentialité et nos Conditions d’utilisation pour en savoir plus.
First, let’s go over the complication we are attempting to avoid…
This is the article we will be discussing today, published in Regional Anesthesia and Pain Medicine early this year. As you can see, the article is rather long, and filled with studies and literature that the group used to come up with their evidence-based recommendations. We will go over some of that literature today… some in more detail than others.
After each of the recommendations later in the presentation, you will see a grade consisting of a number and a letter. Before we get too far into it, I wanted to go over what these grades mean. Letters refer to the strength of evidence, while numbers refer to the general agreement. (Read the slide)
Anticoagulant and regional anaesthesia
DEPARTMENT OF ANAESTHESIA
Improvement in patient outcomes,
including mortality and major morbidity
has been demonstrated with neuraxial
techniques, particularly with epidural
anesthesia and analgesia.
It is due to the attenuation of the
hypercoagulable response and the
associated reduction in the frequency of
Although this beneficial effect of neuraxial
techniques is recognized but the effect is
insufficient as the sole method of
Consequently, anticoagulant, antiplatelet,
and thrombolytic medications have been
increasingly used in the prevention and
treatment of thromboembolism.
Long-term anticoagulation with warfarin
is often indicated for patients with a
history of VTE, mechanical heart valves,
and atrial fibrillation.
In addition, patients with bare metal or
drug-eluting coronary stents require
antiplatelet therapy with aspirin and
thienopyridine derivatives (e.g,
clopidogrel) for varying durations.
Coagulation defects are the principal risk
factors for regional anesthesia.
Spinal hematoma is a rare but potentially
devastating complication of regional
Trauma to epidural veins in the presence of
coagulopathies may result in large
Definition: Symptomatic bleeding within the spinal
Actual incidence of spinal hematoma is unknown
Extensive literature search by M. Tryba (1993)
13 cases after 850,000 epidural anesthetics (<1:150,000)
7 cases after 650,000 spinal anesthetics (<1:220,000)
Study was prior to routine thromboprophylaxis
Recent epidemiologic surveys suggest the risk is higher
Patient with spinal hematoma presents
with severe back pain and neurological
Diagnosis is confirmed by MRI.
Decompression laminectomy is required to
preserve neurologic functions.
Neuraxial blockade should be performed
cautiously in the presence of prophylactic
Pain management is based on appropriate
timings of needle placement and catheter
Clinician should have familiarity with
pharmacology of hemostasis altering drugs,
clinical studies as well as the case reports of
Third Consensus Conference on Regional Anesthesia and Anticoagulation
As published in Regional Anesthesia and Pain Medicine, Vol 35, No 1,
January-February 2010, pp 64-101
Strength of Evidence
A: Randomized, clinical trials and meta-analyses
B: Observational and epidemiologic studies
C: Case reports and expert opinion
Grade of Recommendation
1: General agreement in efficacy
2: Conflicting evidence or opinion on the usefulness
3: General agreement that procedure is not useful
(and may be harmful)
Mechanism of action:
Interferes with the synthesis of Vit K
dependant clotting factors
1. II, VII, IX and X.
2. Anticoagulation of proteins C, and S.
Half life: 40 hours
Dosage: 2-15 mg / day
Monitoring: PT and INR
Caution should be made in performing
neuraxial block in patients recently
discontinued warfarin therapy.
The anticoagulant therapy must be
stopped (ideally 4 – 5 days before
performing the block).
Monitor PT/INR prior to initiation of the
No Regional Anesthesia if in combination
of other drugs affecting the clotting.
If the first dose given 24 hrs earlier- check
Patients receiving warfarin during
epidural analgesia do PT/INR on daily
Check PT/INR before catheter removal if
initial doses of warfarin are given more
than 36 hours preoperatively.
Epidural catheters can be removed if INR
is < 1.5.
Neurological testing of motor and sensory
functions should be done.
Minimize the degree of motor and sensory
If INR > 3, Hold warfarin
Reduced doses of warfarin in patients with
enhanced drug response.
Mechanism of action:
Accelerates the inactivation of factors IIa,
IXa, Xa, XIa, and XIIa by the serine protease
inhibitor, Antithorombin III (AT III).
Half life:1 to 1.5 hours.
Bolus: 80 units / kg or 5000 units
Maintenance: 15 units / kg / hr or 700
to 2000 units / day
For mini dose prophylaxis :
No contraindication. Hold morning dose.
Check platelet count
In pts with combined neuraxial blocks and
Avoid regional anesthesia with other
Avoid RA in patients with medications of
clotting inhibitors in combination.
Delay Heparin dose up to one hour after
Remove catheter 4 hours stopping the dose
and start the dose again after one hour.
Check for motor and sensory blockade.
Consider minimal dose of local anesthetics
for early detection of spinal hematoma.
Combining neuraxial techniques with full
anticoagulation of cardiac surgery
Insufficient data and experience to
determine the risk of hematoma.
Postoperative monitoring of neurological
Selection of solutions to minimize sensory
and motor blockade.
Mechanism of action: Inhibit clotting factor Xa
more than IIa.
Half-life: Three to four times more than
Deltaparin: 2500-5000 u / day
Enoxaparin: 30-40 mg / day
Tinzaparin:175 u / day
Monitoring of anti – Xa level is not
No RA in patients taking other clotting
inhibitors in addition.
In the presence of blood during needle and
Delay LMWH therapy for 24 hours
Should be discussed with the surgeon.
1. Thromboprophylaxis: Needle placement
should be delayed up to 10 – 12 hours.
2. Treatment doses: A delay of at least 24 hours
3. No RA if the dose is given in morning
Postoperative LMWH: may undergo RA
technique, but removal of the catheter
depends upon total daily dose and
a. Twice daily dose:
increased risk of spinal hematoma.
First dose of LMWH should not be
administered 24 hours postoperatively.
Catheters should be removed prior to
initiation of thrombo-prophylaxis.
LMWH dose should be started after 2 hours
removing the catheter.
b. Single daily dose:
First dose should be administered 6 – 8 hours
Second dose after 24 hours and catheters may be
Catheters should be removed after 12 hours of last
LMWH dose can be started after two hours.
ASPIRIN and NSAIDS
Platelet GP IIb/IIIa antagonists
MECHANISM OF ACTION:
Blocks cyclooxygenase. Cyclooxygenase is
responsible for the production of
thromboxane A2 which inhibits platelet
aggregation and causes vasoconstriction.
DURATION OF ACTION:
Irreversible effect on platelets. Effect of
aspirin lasts for the life of the platelet which
is 7-10 days. Long term use of aspirin may
lead to a decrease in prothrombin production
and result in a lengthening of the PT.
MECHANISM OF ACTION:
Inhibits cyclooxygenase by decreasing tissue
DURATION OF ACTION:
Reversible. Duration of action depends on
the half life of the medication used and can
range from 1 hour to 3 days.
Either medication alone does not increase
Need to scrutinize dosages, duration of
therapy and concomitant medications
that may affect coagulation.
No wholly accepted laboratory tests. A
normal bleeding time does not indicate
normal homeostasis. An abnormal
bleeding time does not necessarily
indicate abnormal homeostasis.
History of bruising easily
History of excessive bleeding
MECHANISM OF ACTION:
Interfere with platelet membrane function
by inhibition of adenosine diphosphate (ADP)
induced platelet-fibrinogen binding.
DURATION OF ACTION:
Thienopyridine derivatives exert an
irreversible effect on platelet function for
the life of the platelet.
DC ticlopidine for 14 days prior to a neuraxial
DC clopidogrel for 7 days prior to a neuraxial
There is no accepted laboratory tests for
Mechanism of action: Non peptide inhibitors
of GP IIb / IIIa receptor
Abciximab. Dose:250 micrograms / kg
Eptifibatide. Dose:180 microgram / kg
Tirofiban. Dose: 10 micrograms / kg
No wholly accepted test including the
Careful preoperative assessment is
Platelet GIIb/IIIa Inhibitors:
RA should be avoided 2 days for abciximab and 4-
8 hours for eptifibatide and tirofiban therapy.
If administrated postoperatively following RA,
the patient should be monitored neurologically.
Although the plasma half life of thrombolytic drugs is
mainly hours, it may take days for the thrombolytic
effect to resolve.
No RA in the presence of these drugs.
In patients with catheters already in and
with sudden initiation of these drugs,
Neuraxial monitoring is necessary which should not be
more than 2 hour interval.
Infusion should be limited to drugs minimizing sensory
and motor blockade.
Fibrinogen level measurement.
No definite recommendation regarding the removal of
Patients scheduled for thrombolytic therapy
must be inquired for history of neuroaxial
Patients who received thrombolytic
therapy ,neuroaxial block is contraindicated,
no time interval is outlined.
Antithrombotic medication for DVT
Binds with antithrombin III which
neutralizes factor Xa.
Peak effect in 3 hours with half life of 17-
Need further clinical experience to
Black box warning similar to the LMWH
Bivalirudin- thrombin inhibitor used in
Lepirudin used to treat heparin-induced
Caution advised. No recommendations
related to limited clinical experience.
Is a prodrug that inhibits both free and clot-
The drug is absorbed from the
gastrointestinal tract with a bioavailability of
The half-life is 8 hrs after a single dose and
up to 17 hrs after multiple doses.
Prolongs the aPTT
Is a potent selective and reversible oral
activated factor Xa inhibitor.
Inhibition is maintained for 12 hrs.
Monitored with the PT, aPTT.
For Dabigatran etexilate and Rivaroxaban,
the lack of information regarding the
specifics of block performance and the
prolonged half-life warrants a cautious
For patients undergoing deep plexus or
peripheral block, recommendations regarding
neuraxial techniques, should also be applied
In the absence of a large series of neuraxial
techniques in the pregnant population,
receiving prophylaxis or treatment of VTE,
ASRA guidelines (derived mainly from
surgical patients) should be applied to
Reduces blood pressure, thrombus formation, and serum
lipid and cholesterol levels
Inhibits in vivo platelet aggregation is dose-dependent
Time to normal hemostasis after discontinuation – 7 days
Cognitive disorders, peripheral vascular disease, vertigo,
tinnitus, and altitude sickness
Inhibits platelet activating factor
Time to normal hemostasis after discontinuation – 36 hrs
Protects against effects of stress
May inhibit the coagulation cascade
Time to normal hemostasis after discontinuation – 24 hrs
These represent no added risk for spinal hematoma
These consensus statements represent the collective
experience of recognized experts in neuraxial
anesthesia and anticoagulation. They are based on
case reports, clinical series, pharmacology,
hematology, and risk factors for surgical bleeding.
Alternative anesthetic and analgesic techniques
should be used for the patients, who are at
The patient's coagulation status should be optimized
at the time of spinal or epidural needle/catheter
placement, and the level of anticoagulation must be
carefully monitored during the period of epidural
Indwelling catheters should not be removed in
the presence of therapeutic anticoagulation
because this significantly increase the risk of
Vigilance in monitoring is critical to allow early
evaluation of neurologic dysfunction and prompt
Protocols must be in place for urgent magnetic
resonance imaging and hematoma evacuation if
there is a change in neurological status.