Regional anaesthesia and anticoagulation

Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines

BACKGROUND

Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia.

DESIGN

A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline.

RESULTS

Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%.

DISCUSSION

Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply.

CONCLUSION

In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Regional Anesthesia in Patients of Aged 99 Years in Clopidogrel Use

The risk of neuraxial block in patients treated with antiplatelet drugs are uncertain. Elderly patients often have low physiological reserve, delaying surgery can lead to a high rate of morbidity and mortality. The aim of this paper is to present a case of a patient with 99 years using clopidogrel undergoing regional anesthesia for surgical treatment of hip fracture without complications.

Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature

A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.

Epidural anaesthesia and analgesia for liver resection

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials.

Safe removal of an epidural catheter 72 hours after clopidogrel and aspirin administrations guided by platelet function analysis and thromboelastography

Management of neuraxial anesthesia/analgesia in anticoagulated patient can be challenging. The shortest safe time to remove epidural catheter, after a patient receives long-acting dual antiplatelet agents (clopidogrel and aspirin), is unclear. American Society of Regional Anesthesiology (ASRA) guidelines recommend seven days interval for the epidural placement after clopidogrel administration. However ASRA Guideline did not specify the time for epidural catheter removal, and did not specify how much time elapse necessary after dual antiplatelet therapy with clopidogrel and aspirin. We report a case of safe removal of epidural catheter 72 hours after oral dose of clopidogrel and aspirin with a normal platelet function analysis and normal thromboelastography before removal.

Regional anesthesia for vascular surgery

Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.

Cesarean delivery in the obese parturient: anesthetic considerations

Obesity is a worldwide health problem and its prevalence is reaching epidemic proportions. As obesity does not spare women of childbearing age, obstetric anesthesiologists will increasingly be exposed to the challenges of anesthesia in this population. The purpose of this article is to give the reader a thorough understanding of the anesthetic implications of obesity relating to cesarean deliveries. Obesity is associated with hypertension, diabetes, obstructive sleep apnea and other comorbidities. It increases the risk of cesarean delivery, postpartum wound infections and deep venous thromboembolism. Obese parturients are prone to anesthetic complications such as aspiration of gastric contents, difficult monitoring, positioning, airway management and challenging neuraxial techniques. A thorough precesarean delivery preparation should include an evaluation by an anesthesiologist for women with a BMI over 40 kg/m² and institution of an antacid prophylaxis protocol, thromboprophylaxis and antibiotic prophylaxis. Regional anesthesia should ideally be used in all obese parturients unless contraindicated. The goals of postpartum care include efficacious analgesia, physiotherapy and early mobilization. Monitoring and vigilance in an intensive care unit or step-down units should be considered for morbidly obese women.