Recommendations of the European Society of AnesthesiologyGogarten, Wiebke; Vandermeulen, Erik; Van Aken, Hugo; Kozek, Sibylle; Llau, Juan V; Samama, Charles M European Journal of Anaesthesiology. 27(12):999-1015, December 2010. Miljenko Mratinović Tomislav Čutura
Spinal epidural haematoma in patients onantithrombotic drugsFirst national recommendations on neuraxial anaesthesia and antithrombotic drugs 1997. German Society for Anaesthesiology and Intensive Care 1998. ASRA 2000. Belgian anaesthesiologists Regional anaesthesia and antithrombotic agents
Recommendations are based on case report and expert opinion ( mainly on knowledge of the pharmacokinetics of individual agent)Mostly the time interval between cessation of medication and neuraxial blocade at 2x the elimination half-life of the drug. Regional anaesthesia and antithrombotic agents
The risk of haemorrhage ↓ spinal anaesthesia ↑epidural catether anaesthesia½ of all cases of bleeding occur during the removal of an epidural catether Regional anaesthesia and antithrombotic agents
Tromboprophylaxis preoperatively vs. postoperatively (exeption neurosurgery)A meta-analysis of preoperative vs. postoperative studies shows that LMWH given 12 h preoperatively does not reduce the risk of VTE compared to postoperative regimeGerman guidelines on thromboprophylaxis refer to preoperative administration only as an option, not as a requirement. Regional anaesthesia and antithrombotic agents
Tromboprophylaxis preoperatively vs. postoperatively (exeption neurosurgery)Because preoperative vs. postoperative thromboprophylaxis is not proven to be beneficial, in the presence of acetylsalicylic acid, VTE prophylaxis should be started postoperatively.AHA recommends acetylsalicylic acid administration on a life-long basis and perioperative interruptions should be avoided in patients with DES/BMS. Regional anaesthesia and antithrombotic agents
HeparinsBinds to the enzyme inhibitor antithrombin III (AT)UFH – 1/2 elimination 60 min. 4-6h between iv. administration and puncture or catether manipulation or withdrawal ( aPTT normalised) further administration delayed for 1h ( ACT maintained at 2x the baseline value)LMWH – 1/2 elimination 4-7h 12h between sc. administration and neuraxial blockade or removal of an epidural cateter ( plasma anti-factor Xa activity) Regional anaesthesia and antithrombotic agents
Anti Xa agents inhibitorsFondaparinux - alternative anticoagulant in HIT 1/2 elimination 18h 36h before catether removal, and 12h between the next doseIdrabiotaparinux – 1/2 elimination 135h and up to 66 days no data regarding neuraxial anesthesiaRivaroxaban - 22-26h between the last dose and catether withdrawal next dose may be given after 4-6h Regional anaesthesia and antithrombotic agents
Direct trombin inhibitorsDesirudin, lepirudin - 8-10h between the administration and neuraxial punction Argatroban - administered iv. in treatment of HIT eliminated exclusively by liver 1/2 elimination 35-45 min ( normalisation of aPTT takes 2-4h) Regional anaesthesia and antithrombotic agents
Vitamin K antagonistswarfarin, fluindione, acenocoumarol, phenprocoumonII, VII, IX, X coagulation factorsnormalisation of INR → INR<1,4 ( Vit.K, PCC, FFP) Regional anaesthesia and antithrombotic agents
Platelet aggregation inhibitorsAcetylsalicylic acid irreversible inhibition of cyclo-oxygenase when given in isolation do not increase the risk of spinal epidural haemathoma and are not a contraindication to neuraxial blockThienopyridines - irreversible antagonosing ADP at the platelets purine receptorsTiclopidine - neuraxial regional anesthesia should not be performed until 10 days elapsed between last ingestion and the procedureClopidrogel - 7 days after the last intake Regional anaesthesia and antithrombotic agents
Glycoprotein IIa/IIIb inhibitors - abciximab, tirofibam, eptifibatide the most potent form of platelet inhibition reduces thrombin generation are used only in ACS ( in combination with anticoagulants and aspirin ) cardiac surgery procedures are emergencies with continuing antigoagulation → neuraxial blockade is contrainicated! Regional anaesthesia and antithrombotic agents
Platelet aggregation inhibitorsIf a catheter has to be removed after administration of glycoprotein inhibitors, most guidelines recomend waiting at least 48h after abciximab, and 8-10 h after tirofiban or eptifibatide ( platelet count should be obtained to exclude thrombocytopenia ) Regional anaesthesia and antithrombotic agents
HVALA!Regional anaesthesia and antithrombotic agents
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