Managing anticoagulated patients during neuraxial anaesthesia

Abstract

SummaryThe widespread use of central neuraxial block (CNB) and the prevalence of anticoagulation for different indications have led to an inevitable overlap between the two. The most serious complication of CNB in anticoagulated patients is the risk of spinal/epidural haematoma. Performing CNB in these patients is a complex decision that should take into account the twin risks of bleeding and venous/arterial thrombosis if anticoagulation therapies were to be stopped. Various guidelines have been issued to achieve normal haemostasis and thus allow safe administration of CNB. However, the evidence base for many such recommendations is weak, relying mainly on case reports, small studies and pharmacokinetics of the drugs. Given these limitations it is crucial to fully assess individual risk factors and understand anticoagulant pharmacokinetics in order to appropriately set time intervals for catheter insertion/removal. This paper will review traditional and newer anticoagulation/ antiplatelet therapies with a view to improving the management of anticoagulated patients undergoing CNB.

Comparison of Ultrasound-Guided Femoral Nerve Block with Combined Spinal Epidural Anesthesia in Total Knee Arthroplasty

“…responses can often make CSEA contraindicated (6). These factors often prevent the use of CSEA (13).…”

“…Patients who undergo TKA are generally older and often have impaired cardiovascular and pulmonary functions, and have diseases that threaten spinal stability. These factors also prevent general anesthesia (6). Hemodynamic changes resulting from morbid obesity, anatomic deformities, or antiplatelet or anticoagulant therapy to prevent ischemic cardiac events can often make combined spinal epidural anesthesia (CSEA) inappropriate (7).…”

Preoperative hemostatic assessment: a new and simple bleeding questionnaire

“…7,31 In case of neuraxial anesthesia, intake of drugs that potentially interfere with hemostasis should be carefully considered, as acquired hemostatic disorder due to medication is one of the main risk factors for spinal/epidural hematoma. 32 This study describes how a newly developed questionnaire was applied to a retrospective cohort of patients referred for a hemostatic evaluation because of their bleeding symptoms and to a prospective cohort of controls a priori unaffected by any hemostatic disorder. An appropriately trained healthcare provider can quickly complete the five general questions and the two questions specific to females contained in this questionnaire.…”

How to manage new oral anticoagulants in case of surgery

“…Moreover, after catheter insertion or removal, the antithrombotic drug can be administered after a time corresponding to the clot formation which is around 8 h less the time to reach the peak plasma concentration (Table 5). 13,14 …”

“…While there are no particular recommendations for general anesthesia other than those abovementioned for DOACs withdrawal, neuraxial anesthesia requires close attention in patients taking antithrombotic drugs due to bleeding risk in the phases of insertion and removal of epidural catheter. 13 Epidural catheter can be inserted or removed only after a period of time corresponding to the sum of two half-lives plus the time needed to reach the plasma peak concentration. Moreover, after catheter insertion or removal, the antithrombotic drug can be administered after a time corresponding to the clot formation which is around 8 h less the time to reach the peak plasma concentration (Table 5).…”