Antithrombotic drugs and the risk of bloody punctures in regional anesthesia - a retrospective registry analysis

Literature review of spinal hematoma case reports: causes and outcomes in pediatric, obstetric, neuraxial and pain medicine cases

BACKGROUND

The risk of spinal epidural hematoma (SEH) has been described in the literature but the impact in various patient populations has not been assessed in the same study. We identified the risk factors for SEH and calculated the OR for recovery in the pediatric, adult and obstetric (OB) patients based on the degree of neurological deficit before surgery.

METHODS

Adult non-OB cases were categorized whether they were on anticoagulants or not; SEH was related to neuraxial or pain procedure; or whether there was adherence to the American Society of Regional Anesthesia (ASRA) guidelines. Eligible cases were identified through PubMed and Embase searches in the English literature from 1954 to July 2022.

RESULTS

A total of 940 cases were evaluated. In the pediatric cases, SEH was typically spontaneous, related to coagulopathy or athletic trauma. OB cases were spontaneous or related to neuraxial injections. Among adults on anticoagulant(s), SEH was mostly spontaneous with no related etiology or related to neuraxial procedure. SEH occurred despite adherence to the ASRA guidelines. Among non-OB adults not on anticoagulants, SEH was due to trauma, neuraxial injections, surgery or other causes. Neurological recovery was related to the degree of neurological deficit before surgery.

CONCLUSIONS

Our data show a preponderance of spontaneous SEH in all patient populations. SEH developed even though the ASRA guidelines were followed, especially in patients on multiple anticoagulants. Patients with less impairment prior to surgery had a higher likelihood of complete recovery, regardless of the interval between surgery and onset of symptoms.

Influence of antithrombotic medication on size and neurological outcome of spinal epidural hematoma after neuraxial anesthesia: a systematic review

INTRODUCTION

Anticoagulation guidelines were developed to reduce the potential risk of epidural bleeding following neuraxial anesthesia. However, the influence of antithrombotic medication on size of spinal epidural hematoma and neurological outcome is unclear. Therefore, our aim was to analyze whether there is a correlation.

METHODS

The study was registered at Prospero (CRD42021285833). A systematic search in MEDLINE, EMBASE, CENTRAL, Web of Science and Google Scholar was conducted in August 2023 for studies reporting spinal epidural hematoma following neuraxial anesthesia. Primary endpoints were segmental extension and neurological outcome. Secondary endpoints were age, sex, body mass index, predisposition, American Society of Anesthesiologists physical status, complicated puncture, multiple punctures, bloody puncture, successful puncture, catheter usage, needle size and worst neurological deficit before treatment. Prespecified multivariate regression and propensity score matching was performed. Publications reporting on more than one patient were critically appraised.

RESULTS

A total of 345 cases reported in 304 publications were included. Size of hematoma was not significantly different (antithrombotic medication: OR 0.11, 95% CI (-0.67 to 0.89), p=0.78, 'non-guideline adherent' for puncture/removal: OR 0.13, 95% CI (-0.92 to 1.18), p=0.81). Patients receiving antithrombotic medication were more likely to have persistent neurological deficit (OR 2.00, 95% CI 1.24 to 3.23), p<0.01). Significance persisted after propensity score matching (p=0.04). Patients with non-guideline adherence had a 3.42 higher chance of persistent neurological deficit (95% CI 1.71 to 6.86, p<0.001).

DISCUSSION

Antithrombotic medication is not significantly associated with hematoma size; however, the use of antithrombotic medication doubled the risk for persistent neurological deficit after spinal epidural hematoma.

To drain or not to drain following posttraumatic ear reconstruction with Dieffenbach's postauricular flap in patients with antithrombotic therapy

PURPOSE

To measure the association between drainage use and postoperative complications (POCs) after posttraumatic ear reconstruction (PTER) with Dieffenbach's postauricular flap (DPF) in patients with antithrombotic therapy (ATT).

METHODS

This was a retrospective double-cohort study of patients undergoing posttraumatic DRF with vs. without drainage in 4 maxillofacial units during a 7-year interval. The primary predictor variable was drainage use, and the main outcome was POCs (i.e., auricular haematoma and infection). Descriptive, bi- and multivariate statistics were computed with P ≤ 0.05 defined as statistically significant.

RESULTS

The sample was composed of 365 unilateral PTER patients (14% POCs, 15.6% ATT, 34.5% females) aged 58.1 ± 19.7 years (range, 18-101). Among subjects with ATT, drainage use significantly reduced POCs (OR, 0.5; 95% CI, 0.3 to 0.8; P = 0.009; absolute risk reduction [ASR], 34.04%; NNT, 3), especially when delayed surgery > 5 h after trauma was evident (forward stepwise logistic modelling: OR, 20.6; 95% CI, 2 to 215.9; P = 0.012). Drainage placement under DPF in ATT patients with smoking habit, concomitant diseases (e.g. diabetes mellitus), ear cartilage loss, or wound contamination almost halved POC rates (ASR, 34.5 ± 12.1%; range, 22.1% to 49%). Patient's age, gender, American Society of Anesthesiologists (ASA) class, alcohol misuse, ATT and antibiotic type, and international normalised ratio (INR) before surgery had no meaningful effect on POCs.

CONCLUSIONS

Drainage should be placed under DPF in patients with ATT, regardless of age, gender, ATT and antibiotic type, and preoperative INR.