Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: If Only the Data Were Produced in a River Not a Pond!

Evaluating residual anti-Xa levels following discontinuation of treatment-dose enoxaparin in patients presenting for elective surgery: a prospective observational trial

INTRODUCTION

Prior studies have demonstrated that patients presenting for elective surgery may have higher-than-expected residual anti-Xa level activity at or beyond 24 hours following their last treatment dose of enoxaparin. Given that 24 hours of abstinence is currently recommended by both European and American societies before the performance of neuraxial or deep anesthetic/analgesic procedures, determining the actual timeframe at which residual anti-Xa level activity reliably falls below 0.2 IU/mL, the lower limit of the target range for thromboprophylaxis, is critical.

METHODS

This was a prospective observational trial. Consenting patients on treatment-dose enoxaparin were randomized to either a 24-hour group (last dose at 07:00 the day prior to surgery) or a 36-hour group (last dose at 19:00 2 days prior to surgery). On arrival for surgery, blood samples were obtained to assess residual anti-Xa level activity and renal function. The primary outcome was residual anti-Xa level activity following the last treatment dose of enoxaparin. Incorporating all patients, linear regression modeling was performed to predict the timepoint at which the level of anti-Xa activity reliably fell below 0.2 IU/mL.

RESULTS

103 patients were analyzed. Time from the last dose at which residual anti-Xa activity fell below 0.2 IU/mL, based on the upper bound of the 95% CI, was 31.5 hours. No correlation overall between age, renal function, or sex was found.

CONCLUSION

Residual levels of anti-Xa activity do not reliably fall below 0.2 IU/mL 24 hours following discontinuation of treatment-dose enoxaparin. Therefore, current time-based guidelines are not conservative enough. Routine anti-Xa testing should be strongly considered, or current time-based guidelines should be reassessed.

TRIAL REGISTRATION NUMBER

NCT03296033.

Pachymic acid protects against cerebral ischemia/reperfusion injury by the PI3K/Akt signaling pathway

Pachymic acid (PA) from medicinal fungus Poria cocos has a variety of pharmacological potentials. However, there are no reports of the effects of PA on cerebral ischemia/reperfusion (I/R) injury. The purpose of this study was to investigate the mechanisms of PA on cerebral I/R injury in rats. The effects of PA on cerebral infarction size, brain water content, neurological symptoms and cerebral blood flow were evaluated. Nissl staining was used to observe the damage of ischemic brain neurons after I/R in rats. Apoptosis of ischemic brain neurons after I/R was observed by TUNEL staining. The effect of PA on the expression of some components of PI3K/Akt was detected by Western blotting. PA significantly increased cerebral blood flow after I/R in rats, reduced infarct volume and brain water content, and downgrade neurological function scores, significantly reduced neuronal damage after I/R in rats, and significantly decreased neuronal apoptosis. The effect of PA on rat I/R can be eliminated by LY294002. In addition, PA significantly up-regulated the protein expression of p-PTEN (Ser380), p-PDK1 (Ser241), p-Akt (Ser473), pc-Raf (Ser259) and p-BAD (Ser136), and down-regulated Cleaved caspase protein expression. LY294002 can reverse the effect of PA on the expression of PI3K / Akt signaling pathway related protein in rats after I/R. PA had obviously neuroprotective effects on brain I/R injury and neuronal apoptosis, and its mechanism may be related to activation of PI3K / Akt signaling pathway.