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Scarpelli EM, Park CH, Jeng CL. Regional anesthesia and anticoagulation: a narrative review of current considerations. Int Anesthesiol Clin 2024; 62:1-9. [PMID: 38063032 DOI: 10.1097/aia.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Enrico M Scarpelli
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Christina L Jeng
- Department of Anesthesiology, Perioperative and Pain Medicine; Orthopaedics; and Medical Education, Mount Sinai Hospital, New York, New York
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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Yoon KC, Kim KG, Lee DC, Yoon SJ. Smart syringe using actuator and force sensor for epidural anesthesia injection. Int J Artif Organs 2021; 45:331-336. [PMID: 34915760 DOI: 10.1177/03913988211066501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The anesthesia process in the epidural space is quite difficult as it requires a high level of skill. Therefore, a medical accident occurs, and intensive training is required. In order to reduce these medical accidents, medical technology is being developed, which provides safe and accurate treatment services. This paper proposes a smart syringe design for safe and accurate anesthesia in the epidural space. The smart syringe is designed to measure the electrical sensing waveform by using a sensor instead of the sense of the hand during anesthesia and show the position of the needle through external monitoring. To design a smart syringe, a force sensor, actuator, and CPU were used, and a 3D printer was used to produce the outer shape. An animal test was conducted to evaluate the performance test of the smart syringe, and satisfactory results were obtained by measuring the needle insertion process of the smart syringe and the position of the needle through the animal experiment.
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Affiliation(s)
- Ki-Cheol Yoon
- Department of Biomedical Engineering, College of Medicine, Gachon University, Incheon, Republic of Korea.,Medical Devices R&D Center, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Kwang Gi Kim
- Department of Biomedical Engineering, College of Medicine, Gachon University, Incheon, Republic of Korea.,Medical Devices R&D Center, Gachon University Gil Medical Center, Incheon, Republic of Korea.,Department of Biomedical Engineering, College of Health Science, Gachon University, Incheon, Republic of Korea.,Department of Health Sciences and Technology, Gachon Advanced Institute for Health Sciences and Technology (GAIHST), Gachon University, Incheon, Republic of Korea
| | - Dong Chul Lee
- Department of Anesthesia, Gil Medical Center, Incheon, Republic of Korea
| | - Sang Jin Yoon
- Department of Urology, Gil Medical Center, Incheon, Republic of Korea
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Ranaei-Zamani N, Kaler MK, Khan R. Proteus syndrome in pregnancy: A case report. Obstet Med 2021; 14:253-256. [PMID: 34880940 PMCID: PMC8646214 DOI: 10.1177/1753495x20970791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022] Open
Abstract
Proteus syndrome is a rare, multi-system, genetic syndrome characterised by atypical and excessive growth of skeletal tissue. Clinical presentations include abnormal musculoskeletal growth and cutaneous lesions. Due to its rarity, there have been a limited number of published case reports of Proteus syndrome. This is the first case report on the management of Proteus syndrome in pregnancy. We present the case of a pregnant woman with Proteus syndrome in her first pregnancy in a large teaching hospital and discuss the considerations and challenges faced in her antenatal, intrapartum and postnatal care.
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Affiliation(s)
| | - Mandeep K Kaler
- The Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, UK
| | - Rehan Khan
- The Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, UK
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Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. [SBA 2020: Regional anesthesia guideline for using anticoagulants update]. Rev Bras Anestesiol 2020; 70:364-387. [PMID: 32660771 DOI: 10.1016/j.bjan.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/10/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
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Fonseca NM, Pontes JPJ, Perez MV, Alves RR, Fonseca GG. SBA 2020: Regional anesthesia guideline for using anticoagulants update. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32660771 PMCID: PMC9373103 DOI: 10.1016/j.bjane.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Neuber Martins Fonseca
- Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Disciplina de Anestesiologia, Uberlândia, MG, Brasil; Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Centro de Ensino e Treinamento (CET), Uberlândia, MG, Brasil; Comissão de Normas Técnicas da Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil.
| | - João Paulo Jordão Pontes
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil; European Diploma in Anaesthesiology and Intensive Care, European Society of Anaesthesiology, Bruxelas, Bélgica
| | - Marcelo Vaz Perez
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brasil; Conselho Editorial da Revista Brasileira de Anestesiologia, São Paulo, SP, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Rodrigo Rodrigues Alves
- Hospital Santa Genoveva de Uberlândia, CET/SBA, Uberlândia, MG, Brasil; Título Superior em Anestesiologia (TSA), Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brasil
| | - Gabriel Gondim Fonseca
- Irmandade da Santa Casa de Misericórdia de São Paulo, Anesthesiology Specialization, São Paulo, SP, Brasil
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How I treat patients with hereditary antithrombin deficiency. Blood 2020; 134:2346-2353. [PMID: 31697819 DOI: 10.1182/blood.2019002927] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/16/2019] [Indexed: 11/20/2022] Open
Abstract
Genetic predispositions to venous thromboembolism (VTE) are relatively frequent in the general population and comprise a heterogeneous group of disorders. Whereas the most frequent congenital risk factors for thrombosis only moderately increase the risk, a deficiency in antithrombin (AT), one of the most important natural inhibitors of blood coagulation, carries a higher risk. Congenital AT deficiency is an infrequently encountered genetic risk factor for VTE, and different subtypes vary with regard to their thrombotic risk. Patients with congenital AT deficiency, especially those with quantitative deficiency (type 1), may develop thrombosis early in life and often have a conspicuous family history of first- and second-degree relatives with VTE. Women are particularly affected because of the risk potentiation by combined estrogen/progestogen oral contraceptive use or pregnancy. The lack of controlled trials or even observational studies of large cohorts does not allow therapeutic decisions to be based on scientific evidence. In this review, we will discuss cases with thrombotic manifestations and the tailored management of patients with this congenital thrombosis risk factor.
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Regional Anesthesia in Patients on Anticoagulation Therapies-Evidence-Based Recommendations. Curr Pain Headache Rep 2019; 23:67. [PMID: 31359193 DOI: 10.1007/s11916-019-0805-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Anticoagulant use among patients is prevalent and increasing. It is important for anesthesiologists to be aware of patients on anticoagulants while performing regional anesthesia. RECENT FINDINGS In recent years, the FDA has approved many new anticoagulants. With new drugs coming to the market, new side effect profiles should be considered when treating patients, especially when using regional anesthesia. Both ASRA and European agencies have laid out recommendations regarding anticoagulant use and neuraxial/regional techniques. Regarding newer anticoagulants, the guidelines for discontinuation prior to neuraxial injection are based on pharmacokinetics, including half-life duration for each drug. While each clinical scenario requires an individualized approach, general guidelines can serve as a starting point to help with anesthetic planning and potentially improve patient safety in this evolving field.
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Mogavero T, Pace R, Vetrugno L. Management of peridural catheter removal during dual antiplatelet therapy after postoperative myocardial infarction and drug-eluting stent implantation, applying the "bridging therapy" concept. Minerva Anestesiol 2018; 84:1227-1228. [PMID: 29774732 DOI: 10.23736/s0375-9393.18.12906-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tindaro Mogavero
- Anesthesia and Intensive Care Unit 1, S. Chiara Hospital, Trento, Italy -
| | - Rocco Pace
- Anesthesia and Intensive Care Unit 1, S. Chiara Hospital, Trento, Italy
| | - Luigi Vetrugno
- Department of Medicine, University of Udine, Udine, Italy
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Safe Use of Low-Molecular-weight Heparin in Pediatric Acute Lymphoblastic Leukemia and Lymphoma Around Lumbar Punctures. J Pediatr Hematol Oncol 2017; 39:596-601. [PMID: 28991127 DOI: 10.1097/mph.0000000000000988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.
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Park SK, Choi YS. Treatment Option for Refractory Postherpetic Neuralgia – Transversus Abdominis Plane (TAP) Block: Two Case Reports. Anesth Pain Med 2016; 7:e41378. [PMID: 28920039 PMCID: PMC5554424 DOI: 10.5812/aapm.41378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/18/2016] [Accepted: 11/20/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea
| | - Yun Suk Choi
- Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea
- Corresponding author: Yun Suk Choi, Department of Anesthesiology and Pain Medicine, Jeju National University Hospital, School of Medicine, Jeju National University, Jeju, South Korea. Tel: +82-647172026, Fax: +82-647172042, E-mail:
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Kim YR, Choi JW, Sim WS, Lee CJ, Chang C. The influence of patient position on withdrawal force of lumbar epidural catheters after total knee arthroplasty: A randomized trial. J Clin Anesth 2016; 34:98-104. [PMID: 27687354 DOI: 10.1016/j.jclinane.2016.03.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 03/15/2016] [Accepted: 03/16/2016] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Elderly patients with degenerative knee disease may have accompanying degenerative spine conditions. There are no studies on lumbar epidural catheter withdrawal forces in these patients. The aim of this study was to investigate withdrawal forces and possible associated risk factors in patients undergoing total knee arthroplasty (TKA). DESIGN Prospective randomized trial. SETTING Operating room and ward in a university hospital. PATIENTS Seventy-eight patients aged 65 to 80years who were undergoing TKA and combined spinal epidural anesthesia were enrolled. INTERVENTIONS Lumbar epidural catheterization was performed in a lateral position before surgery and the patients were randomly allocated to one of 3 positions for removal: flexed lateral (L), prone (P), and sitting (S). On the third postoperative day, the lumbar epidural catheters were removed by a single investigator with the patient in the assigned position. MEASUREMENTS We measured the peak tension during catheter withdrawal and evaluated the factors affecting peak tension. MAIN RESULTS The forces required to remove the catheters were considerably greater in the sitting and prone than in the flexed lateral position: group P (3.9N [0.28-10.36]), group S (4.1N [0.04-11.57]), and group L (1.3N [0.07-3.65]) (P<.001). There was a positive correlation between the length of catheter in the epidural space and peak tension (P=.0026, β coefficient=.223). CONCLUSIONS For ease of removal of catheters from the lumbar epidural space, the flexed lateral position is recommended for elderly patients undergoing TKA. When placing the epidural catheter, the physician should be careful not to insert a catheter that is excessively long.
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Affiliation(s)
- Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea.
| | - Ji Won Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea.
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, South Korea.
| | - Chul Joong Lee
- Zein (ZEropaIN) Pain Treatment Clinic, 7 Seongbuk-Ro, Seongbuk-Gu, Seoul, 136-822, Republic of Korea.
| | - Choohoon Chang
- Zein (ZEropaIN) Pain Treatment Clinic, 7 Seongbuk-Ro, Seongbuk-Gu, Seoul, 136-822, Republic of Korea.
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Preoperative hemostatic assessment: a new and simple bleeding questionnaire. Can J Anaesth 2016; 63:1007-15. [PMID: 27369959 DOI: 10.1007/s12630-016-0688-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 03/10/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022] Open
Abstract
PURPOSE Current recommendations for the assessment of the risk of perioperative bleeding limit coagulation testing to patients with a personal and/or family history of bleeding. As no simple preoperative screening questionnaire is currently available, we assessed the performance of a novel screening questionnaire for its ability to detect bleeding disorders. METHODS A dichotomized, seven-point questionnaire named HEMSTOP (Hematoma, hEmorrhage, Menorrhagia, Surgery, Tooth extraction, Obstetrics, Parents) was applied to three groups of subjects: patients referred to hemostasis specialists for bleeding symptoms for whom any kind of perioperative hemostatic precautions were subsequently recommended (n = 38); patients referred to hemostasis specialists for whom precautions were not required (n = 75); healthy volunteers (n = 70). We calculated the sensitivity and specificity of HEMSTOP scores and compared them with the discriminative performances of standard blood coagulation assays (prothrombin time, activated partial thromboplastin time). RESULTS Patients requiring perioperative hemostatic precautions had greater median [interquartile range] HEMSTOP scores (2 [2-3]) than patients not requiring precautions (1 [1-2]) and healthy controls (0 [0-0]); P < 0.001. A HEMSTOP score ≥ 2 had a specificity of 98.6% [95% confidence interval (CI), 92.3 to 100] and a sensitivity of 89.5% (95% CI, 75.2 to 97.1). The 26.3% (95% CI, 13.4 to 43.1) sensitivity of the standard coagulation times was much lower. CONCLUSION The HEMSTOP score discriminates patients at an elevated risk for bleeding with recommended perioperative precautions from those without such recommendations as well as from healthy participants. Further evaluation of the HEMSTOP score is required for a better evaluation of its definitive usefulness to predict the risk of perioperative bleeding.
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Epidural anesthesia for posterior spinal fusion and lumbar surgery in a patient with glanzmann's thrombasthenia – Case report and systematic review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Anestesia epidural para artrodesis e instrumentación de columna lumbar por vía posterior en paciente con trombastenia de Glanzmann: informe de caso y revisión sistemática. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] Open
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Cappelleri G, Fanelli A. Use of direct oral anticoagulants with regional anesthesia in orthopedic patients. J Clin Anesth 2016; 32:224-35. [PMID: 27290980 DOI: 10.1016/j.jclinane.2016.02.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 01/05/2016] [Accepted: 02/22/2016] [Indexed: 12/11/2022]
Abstract
The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.
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Affiliation(s)
- Gianluca Cappelleri
- Anaesthesia and Intensive Care Unit, Azienda Ospedaliera Istituto Ortopedico Gaetano Pini, 20122, Milan, Italy.
| | - Andrea Fanelli
- Anaesthesia and Intensive Care Unit, Policlinico S. Orsola-Malpighi, 40138, Bologna, Italy.
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Epidural anesthesia for posterior spinal fusion and lumbar surgery in a patient with glanzmann’s thrombasthenia - Case report and systematic review☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1097/01819236-201644030-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Halawi MJ, Grant SA, Bolognesi MP. Multimodal Analgesia for Total Joint Arthroplasty. Orthopedics 2015; 38:e616-25. [PMID: 26186325 DOI: 10.3928/01477447-20150701-61] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/17/2014] [Indexed: 02/03/2023]
Abstract
Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.
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Improving Adherence to Practice Guidelines for Anticoagulation in Patients Receiving Neuraxial Anesthesia Using an Electronic Order Entry Alert System. J Patient Saf 2015; 15:218-223. [PMID: 26076079 DOI: 10.1097/pts.0000000000000219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Epidural analgesia is frequently used to alleviate postoperative pain. Though rare, epidural hematoma continues to be a feared complication of neuraxial analgesia. The risk of epidural hematoma is likely increased when certain regimens are used for prophylaxis/treatment of venous thromboembolism. To help decrease the risk, we developed an alert in our electronic medical record to assist providers with adherence to published guidelines addressing neuraxial analgesia and anticoagulation. METHODS Patient data were collected retrospectively 3 months before and 3 months after the initiation of the computerized alert to assess the effectiveness of the alert. Patients were included if they had a procedure code associated with epidural analgesia. Pregnant patients and children were excluded. Type and frequency of antithrombotic medications were recorded for comparison to published practice guidelines. RESULTS Using Poisson regression to describe the data, patients with epidurals after the best practice alert observed a 61% decrease in the expected number of days of exposure to inappropriate doses of anticoagulation versus patients treated before implementation of the alert. CONCLUSION Unapproved antithrombotic administration was significantly reduced after initiation of the alert system. This simple electronic alert was found to have a protective effect for patients receiving both anticoagulation and epidural analgesia.
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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Feinbloom D. Periprocedural management of antithrombotic therapy in hospitalized patients. J Hosp Med 2014; 9:337-46. [PMID: 24550198 DOI: 10.1002/jhm.2166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/08/2014] [Accepted: 01/15/2014] [Indexed: 11/08/2022]
Abstract
The management of antithrombotic medications in patients requiring invasive procedures is a common problem in hospital medicine, for which there is limited evidence to guide clinical decision making. Existing guidelines do not address many hospital-based procedures and have not kept pace with the introduction of newer antiplatelet and anticoagulant medications. This article provides a conceptual framework for the periprocedural management of antithrombotic therapy, with a focus on the procedures that hospitalists are most likely to perform and the pharmacology of the common and newer antithrombotic medications.
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Affiliation(s)
- David Feinbloom
- Section of Hospital Medicine, Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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23
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Estimating the incidence of suspected epidural hematoma and the hidden imaging cost of epidural catheterization: a retrospective review of 43,200 cases. Reg Anesth Pain Med 2014; 38:409-414. [PMID: 23924685 DOI: 10.1097/aap.0b013e31829ecfa6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Hematoma associated with epidural catheterization is rare, but the diagnosis might be suspected relatively frequently. We sought to estimate the incidence of suspected epidural hematoma after epidural catheterization and to determine the associated cost of excluding or diagnosing an epidural hematoma through radiologic imaging. METHODS We conducted an electronic retrospective chart review of 43,200 patient charts using 4 distinct search strategies and cost analysis, all from a single academic institution from 2001 through 2009. The charts were reviewed for use of radiologic imaging studies to identify patients with suspected and confirmed epidural hematomas. Costs for imaging to exclude or confirm the diagnosis were related to the entire cohort. RESULTS In our analysis, during a 9-year period that included 43,200 epidural catheterizations, 102 patients (1/430) underwent further imaging studies to exclude or confirm the presence of an epidural hematoma-revealing 6 confirmed cases and an overall incidence (per 10,000 epidural blocks) of epidural hematoma of 1.38 (95% confidence interval, 0-0.002). Among our patients, 207 imaging studies, primarily lumbar spine magnetic resonance imaging, were performed. Integrating Medicare cost expenditure data, the estimated additional cost during a 9-year period for imaging and hospital charges related to identifying epidural hematomas nets to approximately $232,000 or an additional $5.37 per epidural. CONCLUSIONS Approximately 1 in 430 patients undergoing epidural catheterization will be suspected to have an epidural hematoma. The cost of excluding the diagnosis, when suspected, is relatively low when allocated across all patients undergoing epidural catheterization.
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Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. Pregnancy Hypertens 2014; 4:105-45. [PMID: 26104418 DOI: 10.1016/j.preghy.2014.01.003] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/17/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP). EVIDENCE The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.
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Affiliation(s)
| | - Anouk Pels
- Academic Medical Centre, Amsterdam, The Netherlands
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Martins Fonseca N, Rodrigues Alves R, Pontes JPJ. Recomendações da SBA para segurança na anestesia regional em uso de anticoagulantes. Rev Bras Anestesiol 2014. [DOI: 10.1016/j.bjan.2013.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Fonseca NM, Alves RR, Pontes JPJ. SBA recommendations for regional anesthesia safety in patients taking anticoagulants. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2014; 64:1-15. [PMID: 24565383 DOI: 10.1016/j.bjane.2013.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 04/28/2013] [Indexed: 06/03/2023]
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Benzon H, Avram M, Green D, Bonow R. New oral anticoagulants and regional anaesthesia. Br J Anaesth 2013; 111 Suppl 1:i96-113. [DOI: 10.1093/bja/aet401] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Sagadai S, Panchagnula U, Sundararajan R, Quraishi T. Residual neurological deficit after central neuraxial blocks. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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29
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Kim JH, Cho MR, Kim SO, Kim JE, Lee DK, Roh WS. A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean J Anesthesiol 2012; 62:448-53. [PMID: 22679542 PMCID: PMC3366312 DOI: 10.4097/kjae.2012.62.5.448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 09/13/2011] [Accepted: 09/22/2011] [Indexed: 11/10/2022] Open
Abstract
Background Several factors, such as compromised cardiopulmonary function, anticoagulative therapy, or anatomical deformity in the elderly, prevent general anesthesia and neuraxial blockade from being conducted for total knee replacement arthroplasty (TKRA). We investigated the efficacy of femoral/sciatic nerve block with lateral femoral cutaneous nerve block (FSNB) as an alternative procedure in comparison with combined spinal epidural nerve block (CSE) in patients undergoing TKRA. Methods In this observational study, 80 American Society of Anesthesiologists physical status I-III patients scheduled for elective unilateral TKRA underwent CSE (n = 40) or FSNB (n = 40). Perioperative side effects, intraoperative medications, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale pain scores were assessed. Statistical analysis was done using Chi-square test, Student's t-test, and repeated-measures analysis of variances. Results There was significantly more use of antihypertensives, analgesics, and sedatives in the FSNB group. There were no significant differences of perioperative side effects, duration and remaining amount of intravenous patient-controlled analgesia, rate of satisfaction with the surgical anesthesia and postoperative analgesia, willingness to recommend the same surgical anesthesia and postoperative analgesia to others, and postoperative visual analog scale scores between the two groups. Conclusions FSNB with a sophisticated use of antihypertensives, analgesics, and sedatives to supplement insufficient block offers a practical alternative to CSE for TKRAs.
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Affiliation(s)
- Jong Hae Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Ferreira J, Ferreira D, Viana-Baptista M, Bettencourt P, Cernadas R, Crespo F. Dabigatran for stroke prevention in nonvalvular atrial fibrillation: answers to challenging "real-world" questions. THROMBOSIS 2012; 2012:867121. [PMID: 22645678 PMCID: PMC3356980 DOI: 10.1155/2012/867121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 02/28/2012] [Accepted: 02/29/2012] [Indexed: 12/18/2022]
Abstract
Dabigatran etexilate is a novel, oral, reversible, direct thrombin inhibitor that constitutes a major breakthrough for stroke prevention in patients with nonvalvular atrial fibrillation (AF). Dabigatran was the first new oral anticoagulant approved in Europe and became available in Portugal, for stroke prevention in nonvalvular AF, earlier than in most European countries. This paper is the joint effort of a panel of experts from different specialties and provides information on the use of dabigatran, in anticipation of the challenges that will come with increased usage.
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Affiliation(s)
- Jorge Ferreira
- Serviço de Cardiologia, Hospital de Santa Cruz, Avenida Prof. Reinaldo dos Santos, 2790-134 Carnaxide, Portugal
| | - Daniel Ferreira
- Serviço de Cardiologia, Hospital da Luz, Avenida Lusíada 100, 1500-650 Lisboa, Portugal
| | - Miguel Viana-Baptista
- CEDOC, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Rua da Junqueira 126, 1349-019 Lisboa, Portugal
- Serviço de Neurologia, Hospital Egas Moniz, 1349-019 Lisboa, Portugal
| | - Paulo Bettencourt
- Serviço de Medicina Interna, Hospital de São João, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Rui Cernadas
- Unidade de Saúde Familiar da Aguda, Avenida Padre Guilherme 21, 4405-010 Arcozelo, Portugal
| | - Francisco Crespo
- Hospital de Torres Vedras, Rua Dr. Ricardo Belo, 2560-324 Torres Vedras, Portugal
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Amat-Santos IJ, Rodés-Cabau J, Urena M, DeLarochellière R, Doyle D, Bagur R, Villeneuve J, Côté M, Nombela-Franco L, Philippon F, Pibarot P, Dumont E. Incidence, Predictive Factors, and Prognostic Value of New-Onset Atrial Fibrillation Following Transcatheter Aortic Valve Implantation. J Am Coll Cardiol 2012; 59:178-88. [DOI: 10.1016/j.jacc.2011.09.061] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 08/24/2011] [Accepted: 09/20/2011] [Indexed: 10/14/2022]
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Seow K, Drummond KJ. Subdural spinal haematoma after spinal anaesthesia in a patient taking aspirin. J Clin Neurosci 2011; 18:1713-5. [DOI: 10.1016/j.jocn.2011.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 02/16/2011] [Accepted: 03/22/2011] [Indexed: 10/17/2022]
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