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Nair AS, Rayani BK. New anticoagulants and antiplatelet agents in perioperative period: Recommendations and controversies! Indian J Anaesth 2017; 61:448-449. [PMID: 28584363 PMCID: PMC5444232 DOI: 10.4103/ija.ija_252_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Abhijit S Nair
- Department of Anesthesiology and Pain Management, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Basanth Kumar Rayani
- Department of Anesthesiology and Pain Management, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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Nakamura M, Kamei M, Bito S, Migita K, Miyata S, Kumagai K, Abe I, Nakagawa Y, Nakayama Y, Saito M, Tanaka T, Motokawa S. Spinal anesthesia increases the risk of venous thromboembolism in total arthroplasty: Secondary analysis of a J-PSVT cohort study on anesthesia. Medicine (Baltimore) 2017; 96:e6748. [PMID: 28471968 PMCID: PMC5419914 DOI: 10.1097/md.0000000000006748] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Clinical guidance on the choice of anesthetic modality vis-à-vis the risk of perioperative venous thromboembolism (VTE) is largely lacking because of a paucity of recent evidence. A comparative effect of general anesthesia and neuraxial blockade on the perioperative incidence of VTE has not been well-investigated.We compared the effects of different types of anesthetic modalities on the risk of VTE after total hip arthroplasty (THA) and total knee arthroplasty (TKA).This is a secondary analysis of the Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT). Data pertaining to a total of 2162 patients who underwent THA and TKA at 34 hospitals were included in this analysis. We compared the different anesthetic modalities with respect to the incidence of VTE. The composite end-point was asymptomatic/symptomatic deep vein thrombosis detected using scheduled bilateral ultrasonography up to postoperative day (POD) 10 and fatal/non-fatal pulmonary embolism up to POD 10.The study groups were as follows: general anesthesia (n = 646), combined epidural/general anesthesia (n = 1004), epidural anesthesia (n = 87), and spinal anesthesia (n = 425). On multivariate analysis, only spinal anesthesia was associated with a significant increase in the risk of VTE as compared with that associated with general anesthesia. Propensity score-matched analysis for "combined epidural/general anesthesia group" versus "spinal anesthesia group" demonstrated a 48% higher incidence of VTE (relative risk = 1.48, 95% confidence interval [CI] 1.18-1.85) in the latter.Spinal anesthesia was associated with a higher risk of postoperative VTE, as compared with that associated with combined epidural/general anesthesia, in patients undergoing total arthroplasty.
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MESH Headings
- Aged
- Anesthesia, Epidural/adverse effects
- Anesthesia, General/adverse effects
- Anesthesia, Spinal/adverse effects
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Female
- Humans
- Incidence
- Japan
- Logistic Models
- Male
- Multivariate Analysis
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/epidemiology
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Propensity Score
- Pulmonary Embolism/diagnostic imaging
- Pulmonary Embolism/epidemiology
- Pulmonary Embolism/etiology
- Pulmonary Embolism/prevention & control
- Risk
- Ultrasonography
- Venous Thromboembolism/diagnostic imaging
- Venous Thromboembolism/epidemiology
- Venous Thromboembolism/etiology
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- Mashio Nakamura
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
- Center for Pulmonary Embolism and Venous Thrombosis, Murase Hospital
| | - Masataka Kamei
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
- Department of Clinical Anesthesiology, Mie University Graduate School of Medicine
| | - Seiji Bito
- Division of Clinical Epidemiology, Japanese National Hospital Organization Tokyo Medical Center
| | - Kiyoshi Migita
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
- Department of Rheumatology, Fukushima Medical University
| | - Shigeki Miyata
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kenji Kumagai
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Isao Abe
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Yasuaki Nakagawa
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Yuichiro Nakayama
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Masanobu Saito
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Takaaki Tanaka
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
| | - Satoru Motokawa
- Japanese National Hospital Organization—EBM Study Group, Japanese Study of Prevention and Actual Situation of Venous Thromboembolism after Total Arthroplasty (J-PSVT), Japanese National Hospital Organization
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Atwell TD, Wennberg PW, McMenomy BP, Murthy NS, Anderson JR, Kriegshauser JS, McKinney JM. Peri-procedural use of anticoagulants in radiology: an evidence-based review. Abdom Radiol (NY) 2017; 42:1556-1565. [PMID: 28070656 DOI: 10.1007/s00261-016-1027-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.
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104
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Casey SD, Stevenson DE, Mumma BE, Slee C, Wolinsky PR, Hirsch CH, Tyler K. Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program. West J Emerg Med 2017; 18:585-591. [PMID: 28611877 PMCID: PMC5468062 DOI: 10.5811/westjem.2017.3.32853] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/30/2016] [Accepted: 03/02/2017] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures. METHODS We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation. RESULTS We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period. CONCLUSION Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.
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Affiliation(s)
- Scott D Casey
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Dane E Stevenson
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Bryn E Mumma
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
| | - Christina Slee
- UC Davis Medical Center, Department of Quality and Safety, Sacramento, California
| | - Philip R Wolinsky
- University of California, Davis School of Medicine, Department of Orthopaedic Surgery, Sacramento, California
| | - Calvin H Hirsch
- University of California, Davis School of Medicine, Department of Internal Medicine, Sacramento, California
| | - Katren Tyler
- University of California, Davis School of Medicine, Department of Emergency Medicine, Sacramento, California
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105
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Lagerkranser M. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors. Scand J Pain 2017; 15:118-129. [DOI: 10.1016/j.sjpain.2016.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Background
Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.
Methods
MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.
Results
Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.
Conclusions and implications
The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.
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Affiliation(s)
- Michael Lagerkranser
- Section for Anaesthesiology and Intensive Care Medicine , Department of Physiology and Pharmacology , Karolinska Institutet , 171 77 Stockholm Stockholm , Sweden
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106
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Okitsu K, Iritakenishi T, Iwasaki M, Imada T, Fujino Y. Risk of Hematoma in Patients With a Bleeding Risk Undergoing Cardiovascular Surgery With a Paravertebral Catheter. J Cardiothorac Vasc Anesth 2017; 31:453-457. [DOI: 10.1053/j.jvca.2016.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Indexed: 11/11/2022]
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107
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Kohan L, Salajegheh R, Hamill-Ruth RJ, Yerra S, Butz J. A review and survey of policies utilized for interventional pain procedures: a need for consensus. J Pain Res 2017; 10:625-634. [PMID: 28360531 PMCID: PMC5364016 DOI: 10.2147/jpr.s126851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Other than the newly published anticoagulation guidelines, there are currently few recommendations to assist pain medicine physicians in determining the safety parameters to follow when performing interventional pain procedures. Little information exists regarding policies for oral intake, cumulative steroid dose limits, driving restrictions with and without sedation, and routine medication use for interventional procedures. Methods A 16-question survey was developed on common policies currently in use for interventional pain procedures. The questionnaire was distributed through the American Society of Regional Anesthesia and Pain Medicine and American Academy of Pain Medicine. We sought to statistically analyze the range of policies being used by pain medicine physicians and to determine if there are any commonly accepted standards. Results A total of 337 physicians out of 4037 members responded to our survey with a response rate of 8.4%. A total of 82% of these respondents used a sedative agent while performing an interventional pain procedure. The majority of respondents required drivers after procedures, except after trigger points. A total of 47% indicated that they have an nil per os (NPO) policy for procedures without sedation. A total of 98% reported that they had an anticoagulation policy before an interventional procedure. A total of 17% indicated that the interval between steroid doses was <2 weeks, while 53% indicated that they waited 2–4 weeks between steroid doses. Conclusion Our study has clearly demonstrated a wide variation in the current practice among physicians regarding sedation, NPO status, steroid administration, and the need for designated drivers. There was much higher endorsement of policies regarding anticoagulation. There is an obvious need for evidence-based guidelines for these aspects of interventional pain care to improve patient safety and minimize the risk of adverse events.
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Affiliation(s)
- Lynn Kohan
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - Reza Salajegheh
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | | | - Sandeep Yerra
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
| | - John Butz
- West River Anesthesiology Consultants, Rapid City, SD, USA
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108
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Shaikh SI, Kumari RV, Hegade G, Marutheesh M. Perioperative Considerations and Management of Patients Receiving Anticoagulants. Anesth Essays Res 2017; 11:10-16. [PMID: 28298749 PMCID: PMC5341681 DOI: 10.4103/0259-1162.179313] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin (LMWH), fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring interventions. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease to use and more favorable pharmacodynamic profiles. Increasingly, anesthesiologists are being requested to anesthetize patients who are on some form of anticoagulants and hence it is important to have sound understanding of pharmacology, dosing, monitoring, and toxicity of anticoagulants. We searched the online databases including PubMed Central, Cochrane, and Google Scholar using anticoagulants, perioperative management, anesthetic considerations, and LMWH as keywords for the articles published between 1994 and 2015 while writing this review. In this article, we will review the different classes of anticoagulants and how to manage them in the perioperative settings.
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Affiliation(s)
- Safiya Imtiaz Shaikh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - R Vasantha Kumari
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - Ganapati Hegade
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
| | - M Marutheesh
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
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Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, Piccini JP, Jung HS, Washam JB, Welch BG, Zazulia AR, Collins SP. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e604-e633. [PMID: 28167634 DOI: 10.1161/cir.0000000000000477] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.
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110
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Doherty JU, Gluckman TJ, Hucker WJ, Januzzi JL, Ortel TL, Saxonhouse SJ, Spinler SA. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol 2017; 69:871-898. [DOI: 10.1016/j.jacc.2016.11.024] [Citation(s) in RCA: 279] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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111
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Dager W, Hellwig T. Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants. Am J Health Syst Pharm 2017; 73:S14-26. [PMID: 27147455 DOI: 10.2146/ajhp150960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. SUMMARY Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. CONCLUSION With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.
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Affiliation(s)
- William Dager
- University of California Davis Medical Center, Sacramento, CA.
| | - Thaddaus Hellwig
- South Dakota State University College of Pharmacy, Sioux Falls, SDSanford USD Medical Center, Sioux Falls, SD
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112
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Eldabe S, Buchser E, Duarte RV. Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature. PAIN MEDICINE 2017; 17:325-36. [PMID: 26814260 DOI: 10.1093/pm/pnv025] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Spinal cord and peripheral neurostimulation techniques have been practiced since 1967 for the relief of pain, and some techniques are also used for improvement in organ function. Neuromodulation has recognized complications, although very rarely do these cause long-term morbidity. The aim of this article is to present a review of complications observed in patients treated with neurostimulation techniques. METHODS A review of the major recent publications in the literature on the subjects of spinal cord, occipital, sacral, and peripheral nerve field stimulation was conducted. RESULTS The incidence of complications reported varies from 30% to 40% of patients affected by one or more complications. Adverse events can be subdivided into hardware-related complications and biological complications. The commonest hardware-related complication is lead migration. Other lead related complications such as failure or fracture have also been reported. Common biological complications include infection and pain over the implant. Serious biological complications such as dural puncture headache and neurological damage are rarely observed. CONCLUSIONS Spinal cord and peripheral neurostimulation techniques are safe and reversible therapies. Hardware-related complications are more commonly observed than biological complications. Serious adverse events such as neurological damage are rare.
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113
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Deer TR, Provenzano DA, Hanes M, Pope JE, Thomson SJ, Russo MA, McJunkin T, Saulino M, Raso LJ, Lad SP, Narouze S, Falowski SM, Levy RM, Baranidharan G, Golovac S, Demesmin D, Witt WO, Simpson B, Krames E, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC) Recommendations for Infection Prevention and Management. Neuromodulation 2017; 20:31-50. [PMID: 28042909 DOI: 10.1111/ner.12565] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique. METHODS The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations. RESULTS The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices. CONCLUSION Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.
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Affiliation(s)
| | | | | | | | - Simon J Thomson
- Pain Management and Neuromodulation Centre, Basildon & Thurrock University Hospitals, NHS, Trust, UK
| | | | | | | | | | - Shivanand P Lad
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Samer Narouze
- Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | | | | | | | | | - Didier Demesmin
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - William O Witt
- Cardinal Hill Pain Institute (emeritus), Lexington, KY, USA
| | - Brian Simpson
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Elliot Krames
- Pacific Pain Treatment Center (ret.), San Francisco, CA, USA
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114
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Deer TR, Lamer TJ, Pope JE, Falowski SM, Provenzano DA, Slavin K, Golovac S, Arle J, Rosenow JM, Williams K, McRoberts P, Narouze S, Eldabe S, Lad SP, De Andrés JA, Buchser E, Rigoard P, Levy RM, Simpson B, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC) Safety Guidelines for the Reduction of Severe Neurological Injury. Neuromodulation 2017; 20:15-30. [PMID: 28042918 DOI: 10.1111/ner.12564] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/07/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. METHODS The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past two decades the INS has established a process to use best evidence to improve care. This article updates work published by the NACC in 2014. NACC authors were chosen based on nomination to the INS executive board and were selected based on publications, academic acumen, international impact, and diversity. In areas in which evidence was lacking, the NACC used expert opinion to reach consensus. RESULTS The INS has developed recommendations that when properly utilized should improve patient safety and reduce the risk of injury and associated complications with implantable devices. CONCLUSIONS On behalf of INS, the NACC has published recommendations intended to reduce the risk of neurological injuries and complications while implanting stimulators.
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Affiliation(s)
| | | | | | | | | | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Jeffrey Arle
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joshua M Rosenow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kayode Williams
- Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Samer Narouze
- Summa Western Reserve Hospital, Cuyahoga Falls, OH, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Shivanand P Lad
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Jose A De Andrés
- Valencia School of Medicine, Hospital General Universitario, Valencia, Spain
| | - Eric Buchser
- Anaesthesia and Pain Management Department, EHC Hosptial, Morges, and CHUV University Hospital, Lausanne, Switzerland
| | | | | | - Brian Simpson
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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115
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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116
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Deer TR, Narouze S, Provenzano DA, Pope JE, Falowski SM, Russo MA, Benzon H, Slavin K, Pilitsis JG, Alo K, Carlson JD, McRoberts P, Lad SP, Arle J, Levy RM, Simpson B, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Bleeding and Coagulation Management in Neurostimulation Devices. Neuromodulation 2017; 20:51-62. [DOI: 10.1111/ner.12542] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022]
Affiliation(s)
| | - Samer Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | | | | | | | | | | | | | - Shivanand P. Lad
- Division of Neurosurgery; Duke University Medical Center; Durham NC USA
| | - Jeffrey Arle
- Neurosurgery, Beth Israel Deaconess Medical Center; Boston MA USA
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Ianchulev SA. Anesthesia for Endovascular Aortic Aneurysm Repair (EVAR). Anesthesiology 2017. [DOI: 10.1007/978-3-319-50141-3_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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118
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Cowan R, Lim JH, Ong T, Kumar A, Sahota O. The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care. Drugs Aging 2017; 34:1-11. [PMID: 27913981 DOI: 10.1007/s40266-016-0427-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia, Epidural/methods
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthesia, Conduction/methods
- Anesthesia, General/methods
- Anesthesia, Spinal/methods
- Female
- Hip Fractures/drug therapy
- Hip Fractures/surgery
- Humans
- Male
- Nerve Block/methods
- Pain/prevention & control
- Pain Management/methods
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Affiliation(s)
- Rachel Cowan
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Jun Hao Lim
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
| | - Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK.
| | - Ashok Kumar
- School of Medicine, University of Nottingham, Medical School, Nottingham, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, HCOP Research Office, Nottingham University Hospitals NHS Trust, F Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK
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119
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Abstract
Cardiomyopathy is considered as a heart muscle disease of multiple aetiologies, unlike other cardiac diseases related to a definitive pathophysiology. With more and more research and with the advent of genetic analysis pin pointing the disease causing mutations, causative factors have been defined and classifications and definitions have changed over time. Patients with these conditions present to anaesthesiologists in elective and emergency situations, placement of automated internal cardioverter defibrillator (AICD) devices or biventricular pacing but may also be diagnosed at anaesthetic pre-assessment. We describe cardiomyopathies such as dilated cardiomyopathy, hypertrophic cardiomyopathy, post-partum cardiomyopathy and Takotsubo cardiomyopathy in brief and their anaesthetic management.
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Affiliation(s)
- Rajiv Juneja
- Department of Cardiac Anaesthesia, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Prajeesh M Nambiar
- Department of Cardiac Anaesthesia, Medanta - The Medicity, Gurgaon, Haryana, India
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Almeida CR, Francisco EM, Pinho-Oliveira V, Assunção JP. Fascia iliaca block associated only with deep sedation in high-risk patients, taking P2Y12 receptor inhibitors, for intramedullary femoral fixation in intertrochanteric hip fracture: a series of 3 cases. J Clin Anesth 2016; 35:339-345. [DOI: 10.1016/j.jclinane.2016.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/09/2016] [Accepted: 08/14/2016] [Indexed: 10/20/2022]
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McCrum C. Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations. Musculoskeletal Care 2016; 14:252-266. [PMID: 27297723 DOI: 10.1002/msc.1145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.
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Affiliation(s)
- Carol McCrum
- East Sussex Healthcare NHS Trust, Eastbourne, UK
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122
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Lessire S, Douxfils J, Pochet L, Dincq AS, Larock AS, Gourdin M, Dogné JM, Chatelain B, Mullier F. Estimation of Rivaroxaban Plasma Concentrations in the Perioperative Setting in Patients With or Without Heparin Bridging. Clin Appl Thromb Hemost 2016; 24:129-138. [PMID: 27811211 DOI: 10.1177/1076029616675968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Estimation of residual rivaroxaban plasma concentrations may be requested before invasive procedures and some patients at high thromboembolic risk will have a bridging therapy with heparins when rivaroxaban is interrupted. OBJECTIVE The objective of this study was to assess the performance of the STA-Liquid Anti-Xa assay (STA LAX) and the low and normal procedures of the Biophen Direct Factor Xa Inhibitors (DiXaI) assay, in patients with and without bridging with low-molecular-weight heparins (LMWHs). MATERIALS AND METHODS Seventy-nine blood samples were collected from 77 patients on rivaroxaban at CTROUGH or before an invasive procedure. Rivaroxaban plasma concentrations were estimated using Biophen DiXaI, Biophen DiXaI LOW, and STA LAX and compared to liquid chromatography coupled with mass spectrometry (LC-MS/MS) measurements. Stratifications were performed according to heparin bridging. RESULTS The Biophen DiXaI LOW and STA LAX showed better correlation with LC-MS/MS measurements than Biophen DiXaI in patients not bridged with LMWH (R: 0.97, 0.96, and 0.91, respectively). However, the performance of Biophen DiXaI LOW and STA LAX decreased when residual LMWH activity was present (R: 0.18 and 0.19 respectively) demonstrating that these tests are not specific to rivaroxaban. CONCLUSION In patients not bridged with LMWH, we suggest to use the Biophen DiXaI LOW and STA LAX for the estimation of rivaroxaban concentrations <50 ng/mL. These results should be confirmed on a larger cohort of patients. Patients bridged with LMWH have inaccurate estimates of low levels of rivaroxaban and the 3 assays studied should not be used to estimate if it is safe to perform a procedure.
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Affiliation(s)
- Sarah Lessire
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium.,2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Lionel Pochet
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Anne-Sophie Dincq
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- 3 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Maximilien Gourdin
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Bernard Chatelain
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - François Mullier
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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123
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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124
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Keeling D, Tait RC, Watson H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematol 2016; 175:602-613. [DOI: 10.1111/bjh.14344] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/26/2016] [Accepted: 07/31/2016] [Indexed: 12/14/2022]
Affiliation(s)
- David Keeling
- Oxford University Hospitals NHS Foundation Trust; Oxford UK
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125
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Bell BR, Spyropoulos AC, Douketis JD. Perioperative Management of the Direct Oral Anticoagulants. Hematol Oncol Clin North Am 2016; 30:1073-84. [DOI: 10.1016/j.hoc.2016.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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126
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127
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Bilsky GS, Saulino M, O'Dell MW. Does Every Patient Require an Intrathecal Baclofen Trial Before Pump Placement? PM R 2016; 8:802-7. [DOI: 10.1016/j.pmrj.2016.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/15/2016] [Indexed: 11/16/2022]
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128
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Saulino MF, Patel T, Fisher SP. The Application of Failure Modes and Effects Analysis Methodology to Intrathecal Drug Delivery for Pain Management. Neuromodulation 2016; 20:177-186. [PMID: 27477689 PMCID: PMC5324639 DOI: 10.1111/ner.12475] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 05/27/2016] [Accepted: 06/13/2016] [Indexed: 11/30/2022]
Abstract
Objective This study aimed to utilize failure modes and effects analysis (FMEA) to transform clinical insights into a risk mitigation plan for intrathecal (IT) drug delivery in pain management. Methods The FMEA methodology, which has been used for quality improvement, was adapted to assess risks (i.e., failure modes) associated with IT therapy. Ten experienced pain physicians scored 37 failure modes in the following categories: patient selection for therapy initiation (efficacy and safety concerns), patient safety during IT therapy, and product selection for IT therapy. Participants assigned severity, probability, and detection scores for each failure mode, from which a risk priority number (RPN) was calculated. Failure modes with the highest RPNs (i.e., most problematic) were discussed, and strategies were proposed to mitigate risks. Results Strategic discussions focused on 17 failure modes with the most severe outcomes, the highest probabilities of occurrence, and the most challenging detection. The topic of the highest‐ranked failure mode (RPN = 144) was manufactured monotherapy versus compounded combination products. Addressing failure modes associated with appropriate patient and product selection was predicted to be clinically important for the success of IT therapy. Conclusions The methodology of FMEA offers a systematic approach to prioritizing risks in a complex environment such as IT therapy. Unmet needs and information gaps are highlighted through the process. Risk mitigation and strategic planning to prevent and manage critical failure modes can contribute to therapeutic success.
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Affiliation(s)
| | - Teresa Patel
- Senior Medical Science Liaison, Northeast, Mallinckrodt Pharmaceuticals, Hazelwood, MO, USA
| | - Stanley P Fisher
- Co-Director, Saint Luke's Marion Bloch Neuroscience Institute, Kansas City, MO, USA
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129
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Boster AL, Bennett SE, Bilsky GS, Gudesblatt M, Koelbel SF, McManus M, Saulino M. Best Practices for Intrathecal Baclofen Therapy: Screening Test. Neuromodulation 2016; 19:616-22. [PMID: 27434115 DOI: 10.1111/ner.12437] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 02/24/2016] [Accepted: 03/02/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intrathecal baclofen (ITB) screening assesses response to a test dose of ITB on spasticity and function and identifies adverse reactions. METHOD An expert panel consulted on best practices after conducting an extensive literature search and conducting an online survey. RESULTS A successful trial may confirm predetermined goals, which may include improved mobility/positioning, decreased time/improved independence for activities, less home exercise, better wheelchair tolerance, decreased caregiver time, improved sleep, and reduced pain, or may modify goals and expectations. Individuals should not be tested in the presence of active medical issues (e.g., MS exacerbations, active urinary tract infection, nonhealing wounds). Oral antispasmodics can be weaned before trial if a goal is to eliminate them. The standard baclofen test dose is a 50-mcg bolus, 25 mcg in very small children or patients who rely on spasticity for mobility. Patients unresponsive to the standard dose may require 75 mcg or 100 mcg; 24 hours should elapse between bolus doses. Cardiopulmonary parameters should be checked frequently during the first two hours postinjection, and spasticity measures assessed at least twice within four hours. Observation continues until the patient is stable and recovers from hypertonia. Adverse events include spinal headaches, nausea/vomiting, urinary retention, hypotension, seizures, drowsiness/sedation, respiratory depression, and coma. Before implantation, team members must discuss starting dose, drug concentration, delivery mode, pump size and location, and catheter tip placement. Patients/caregivers should understand the commitment necessary for ITB therapy. CONCLUSIONS Screening helps identify appropriate candidates for ITB.
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Affiliation(s)
| | - Susan E Bennett
- State University of New York (SUNY) at Buffalo, Buffalo, NY, USA
| | | | - Mark Gudesblatt
- Brookhaven Memorial Hospital Medical Center, South Shore Neurologic Associates, Islip, NY, USA
| | | | - Maura McManus
- Alfred I DuPont Hospital for Children, The Sidney Kimmel Medical College, Thomas Jefferson University, Wilmington, DE, USA
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130
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Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34:586-99. [PMID: 27687455 DOI: 10.1016/j.jclinane.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/10/2023]
Abstract
As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.
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131
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132
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Moeschler SM, Warner NS, Lamer TJ, Bendel MA, Warner MA, Eldrige JS, Mauck WD, Gazelka HM, Kor DJ, Hoelzer BC. Bleeding Complications in Patients Undergoing Percutaneous Spinal Cord Stimulator Trials and Implantations. PAIN MEDICINE 2016; 17:2076-2081. [PMID: 27296055 DOI: 10.1093/pm/pnw124] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Spinal cord stimulators (SCS) are indicated for the management of multiple pain states with strong evidence. Recent guidelines recommend discontinuing aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) for the described procedures. The goal of this investigation is to assess the rate of bleeding and neurologic sequelae in patients undergoing SCS trials and implantation. METHODS This is a retrospective review from 2005 through 2014 of all patients 18 years or older undergoing the following procedures: Percutaneous SCS implantations, SCS revisions, and SCS trials. Baseline characteristics, antiplatelet and anticoagulation medications, coagulation parameters, and procedural details were extracted. The primary outcome was the presence of a bleeding complication within 31 days of the procedure requiring emergency medicine, neurology, or neurosurgical evaluation. The neurological complication was independently categorized for its potential relationship to procedural bleeding, and periprocedural red blood cell transfusion requirements were analyzed as a secondary outcome. RESULTS A total of 642 percutaneous SCS procedures were performed on 421 unique patients, including 346 SCS trials, 255 SCS implantations, and 41 revision surgeries. Patients had received aspirin or NSAIDs within 7 days of needle placement for 101 procedures (15.7%). There were no bleeding or neurological complications identified in this cohort. CONCLUSION Although the incidence of epidural hematoma is low, the development of bleeding complications following SCS lead placement can be devastating. In the present investigation, we identified no cases of epidural hematoma following percutaneous SCS lead placement, including more than 100 patients receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to better define the relationships between periprocedural aspirin and NSAID utilization and bleeding complications.
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Affiliation(s)
| | | | - Tim J Lamer
- Departments of *Anesthesiology.,Divisions of Pain Medicine and
| | - Markus A Bendel
- Departments of *Anesthesiology.,Divisions of Pain Medicine and
| | | | - Jason S Eldrige
- Departments of *Anesthesiology.,Divisions of Pain Medicine and
| | - William D Mauck
- Departments of *Anesthesiology.,Divisions of Pain Medicine and
| | | | - Daryl J Kor
- Departments of *Anesthesiology.,Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bryan C Hoelzer
- Departments of *Anesthesiology.,Divisions of Pain Medicine and
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133
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Mahapatra S, Chandrasekhara NS, Upadhyay SP. Spinal epidural haematoma following removal of epidural catheter after an elective intra-abdominal surgery. Indian J Anaesth 2016; 60:355-7. [PMID: 27212725 PMCID: PMC4870951 DOI: 10.4103/0019-5049.181610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Sudeep Mahapatra
- Department of Anaesthesiology, Sagar Hospital, Bengaluru, Karnataka, India
| | - N S Chandrasekhara
- Department of Anaesthesiology, Sagar Hospital, Bengaluru, Karnataka, India
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134
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Schneider B, Zheng P, Mattie R, Kennedy DJ. Safety of epidural steroid injections. Expert Opin Drug Saf 2016; 15:1031-9. [DOI: 10.1080/14740338.2016.1184246] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Byron Schneider
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Patricia Zheng
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - Ryan Mattie
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
| | - David J. Kennedy
- Department of Orthopedics, Division of Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, USA
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135
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Ghaly RF, Lissounov A, Candido KD, Knezevic NN. Are there a guidelines for implantable spinal cord stimulator therapy in patients using chronic anticoagulation therapy? - A review of decision-making in the high-risk patient. Surg Neurol Int 2016; 7:33. [PMID: 27127698 PMCID: PMC4838920 DOI: 10.4103/2152-7806.179855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/16/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Spinal cord stimulators (SCSs) are gaining increasing indications and utility in an expanding variety of clinical conditions. Complications and initial expenses have historically prevented the early use of SCS therapy despite ongoing efforts to educate and promote its utilization. At present, there exists no literature evidence of SCS implantation in a chronically anticoagulated patient, and neuromodulation manufacturers are conspicuously silent in providing warnings or recommendations in the face of anticoagulant use chronically. It would appear as through these issues demand scrutiny and industry as well as neuromodulation society advocacy and support in terms of the provision of coherent guidelines on how to proceed. CASE DESCRIPTION A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. DESCRIPTION A 79-year-old male returned to the neurosurgical clinic with persistent low back pain and leg heaviness due to adjacent level degenerative spondylosis and severe thoracic spinal stenosis. The patient had a notable history of multiple comorbidities along with atrial fibrillation requiring chronic anticoagulation. On initial presentation, he was educated with three choice of conservative medical therapy, intrathecal drug delivery system implantation, or additional lumbar decompression laminectomy with instrumented fusion of T10-L3 and a palliative surgical lead SCS implantation. CONCLUSION Our literature search did not reveal any evidence of SCS therapy among patients with chronic anticoagulation. This case illustrated a complicated clinical case scenario wherein a percutaneous SCS implantation would normally be contraindicated due to severe thoracic spinal stenosis and chronic anticoagulation which could lead to possible paralysis or even a lethal consequences associated with the possible formation of a thoracic epidural hematoma.
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Affiliation(s)
- Ramsis F Ghaly
- Ghaly Neurosurgical Associates, Aurora, IL, USA; Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, JHS Hospital of Cook County, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Alexei Lissounov
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA
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Chang B, Urman RD. Non-operating Room Anesthesia: The Principles of Patient Assessment and Preparation. Anesthesiol Clin 2016; 34:223-240. [PMID: 26927750 DOI: 10.1016/j.anclin.2015.10.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
A significant number of anesthetics are performed outside of the operating room (OR). Despite the increased requirement for anesthesia services, the framework to perform the necessary preprocedural anesthesia assessments to optimize patients has not been uniformly developed. Performing anesthesia in non-OR locations poses significant and distinct challenges compared with the procedures in the OR. Anesthesiologists are faced with patients with increasingly complicated comorbidities undergoing novel, complex interventional procedures. With unique training in preoperative triaging, and an expertise in intraoperative and postoperative management of complex patients, anesthesiologists can contribute to greater efficiency and patient safety in the non-OR setting.
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Affiliation(s)
- Beverly Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, 300 Pasteur Drive H3580, Stanford, CA 94305, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Johnston D, Stafford M, McKinney M, Deyermond R, Dane K. Peripheral nerve blocks with sedation using propofol and alfentanil target-controlled infusion for hip fracture surgery: a review of 6 years in use. J Clin Anesth 2016; 29:33-9. [DOI: 10.1016/j.jclinane.2015.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 06/10/2015] [Accepted: 10/14/2015] [Indexed: 11/27/2022]
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Abstract
Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation. As these therapies evolve, so too will their placement within the pain care algorithm grounded by a foundation of evidence to improve patient safety and management of patients with difficult neuropathic pain.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, 392 Tesconi Court, Santa Rosa, CA 95401, USA.
| | - David Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA 15143, USA
| | | | - Timothy Deer
- Center for Pain Relief, Charleston, WV 25304, USA
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140
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141
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Narouze SN, Benzon HT, Provenzano D, Buvanendran A, Huntoon MA. Reply to Drs Guffey and Fingerman. Reg Anesth Pain Med 2016; 41:289-90. [DOI: 10.1097/aap.0000000000000366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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143
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Delayed Neuraxial Hematoma in Parturient With Fontan Circulation Following Neuraxial Anesthesia for Cesarean Section. Reg Anesth Pain Med 2016; 41:773-775. [DOI: 10.1097/aap.0000000000000490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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144
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Creating, and Protecting, the American Society of Regional Anesthesia and Pain Medicine’s Intellectual Property. Reg Anesth Pain Med 2016; 41:3-4. [DOI: 10.1097/aap.0000000000000345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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146
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Umegaki T, Hirota K, Ohira S, Uba T, Kusunoki M, Okamoto A, Nishi K, Kamibayashi T. Rapid development of a spinal epidural hematoma following thoracic epidural catheter removal in an esophageal carcinoma surgical patient: a case report. JA Clin Rep 2016; 2:37. [PMID: 29492432 PMCID: PMC5813771 DOI: 10.1186/s40981-016-0060-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
Background The occurrence of spinal epidural hematomas associated with the use of epidural catheters is relatively rare. Furthermore, it is unusual for hematoma-associated neurological symptoms to occur within 15 min of removing a catheter. Here, we report our experience with an esophageal carcinoma surgical patient who developed an epidural hematoma almost immediately after catheter removal, resulting in paralysis of his lower extremities. The patient achieved full neurological recovery following prompt diagnosis and surgical intervention. Case presentation A 68-year-old man was admitted with esophageal carcinoma and underwent video-assisted thoracoscopic esophagectomy followed by posterior mediastinal gastric tube reconstruction. During surgery, the patient was administered both general and epidural anesthesia. The epidural catheter was inserted approximately 5 cm into the epidural space at the Th6–7 level. The patient was extubated the following day in the general intensive care unit. Two days after surgery, the d-dimer level was high at 36.9 μg/mL (reference range 0–0.9 μg/mL), and we decided to administer an anticoagulant (enoxaparin sodium) to prevent thrombosis. The epidural catheter was removed 2 h prior to the scheduled administration of enoxaparin sodium. However, the patient reported a complete lack of strength in his lower extremities 15 min after catheter removal. Upon examination, the manual muscle testing score was 1 out of 5, and the patient experienced impaired touch sensation and cold sensation below Th4. An emergency magnetic resonance imaging scan was performed 2 h after catheter removal, which revealed a possible spinal epidural hematoma spreading from Th3 to Th6. Three hours after catheter removal, we began emergency surgery to evacuate the hematoma, which had spread to Th7. After surgery, the patient showed improvements in touch sensation, cold sensation, and motor function. The patient was able to walk 2 days after hematoma removal. Conclusions It is highly unusual for a spinal epidural hematoma to develop so rapidly after the removal of an epidural catheter. This case emphasizes the need for vigilant patient monitoring, rapid diagnosis, and prompt surgery to ensure adequate neurological recovery in these patients.
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Affiliation(s)
- Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Kiichi Hirota
- Department of Human Stress Response Science, Institute of Biomedical Science, Kansai Medical University, Osaka, Japan
| | - Sayaka Ohira
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Takeo Uba
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Munenori Kusunoki
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Akihisa Okamoto
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Kenichiro Nishi
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
| | - Takahiko Kamibayashi
- Department of Anesthesiology, Kansai Medical University Hospital, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka 573-1191 Japan
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Perioperative Management of Patients Receiving Pentosan Polysulfate Sodium (Elmiron). Reg Anesth Pain Med 2016; 41:658. [DOI: 10.1097/aap.0000000000000450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pertovaara A, Breivik H. Pain treatment with intrathecal corticosteroids: Much ado about nothing? But epidural corticosteroids for radicular pain is still an option. Scand J Pain 2016; 10:82-84. [PMID: 28361777 DOI: 10.1016/j.sjpain.2015.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Antti Pertovaara
- Department of Physiology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Harald Breivik
- Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway
- Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
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Unintended Impact of New Guidelines for Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2016; 41:289. [DOI: 10.1097/aap.0000000000000299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis 2016; 41:92-128. [PMID: 26780741 PMCID: PMC4715853 DOI: 10.1007/s11239-015-1309-0] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Venous thromboembolism (VTE), which may manifest as pulmonary embolism (PE) or deep vein thrombosis (DVT), is a serious and potentially fatal condition. Treatment and prevention of obstetric-related VTE is complicated by the need to consider fetal, as well as maternal, wellbeing when making management decisions. Although absolute VTE rates in this population are low, obstetric-associated VTE is an important cause of maternal morbidity and mortality. This manuscript, initiated by the Anticoagulation Forum, provides practical clinical guidance on the prevention and treatment of obstetric-associated VTE based on existing guidelines and consensus expert opinion based on available literature where guidelines are lacking.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), 1280 Main Street West, HSC 3W11, Hamilton, ON, L8S 4K1, Canada.
| | - Saskia Middeldorp
- Department of Vascular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Rodger
- Departments of Medicine, Epidemiology and Community Medicine, and Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Ian Greer
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
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