2.dani koagulacije

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HUGE TOPIC IN 15MINS!!!

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BENEFITS OF NEURAXIAL BLOCKADE
↓ nausea and vomiting
↓ blood loss
↓ incidence of graft occlusion
Superior postoperative pain control
Less alteration to the cardiopulmonary
status of the patient

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• SH is a rare but severe complication to central neuraxial blockade .
• Presenting symptoms are starting with leg numbness, followed by back
pain, sensory loss, leg weakness, and finally paraplegia, evolving over
minutes, hours or even days.
• Neurological deficits are seen in about 80% of the cases.
• Surgical evacuation of the haematoma is indicated in most cases with
neurological deficits.
• Laminectomy within 12 h leads to favourable outcomes in about 50%.
SPINAL HAEMATOMA

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CNB No of cases Denominator Incidence
SPA1 8 1 260 000 1:160 000
EDA1 25 450 000 1:18 0002
SCS3 41 5 458 1:133
1. Data from Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-99.
Anesthesiology 2004; 101: 950–9.
1. Incidence 1:200 000 in obstetric, and 1:10 300 in perioperative pain relief.
2. Data from Petraglia FW, et al. The incidence of spinal cord injury in implantation of percutaneous and paddle electrodes for spinal cord stimulation.
Neuromodulation 2016;19:85-90.
CNB = Central Neuraxial Block
SPA = Spinal Anaesthesia
EDA = Epidural Anaesthesia, incl. combined spinal/epidural anaesthesia (CSE)
SCS = Percutaneous Spinal Cord Stimulation
INCIDENCE OF SPINAL HAEMATOMA WITH DIFFERENT
NEURAXIAL TECHNIQUES

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Author(s) Years covered No of cases
Males Females
Ratio %
Male Female
Moen et al 2004 1990-1999 9 22 29 71
Pitkänen et al 2013 2000-2009 4 9 31 69
Lagerkranser 2017 1994-2015 53 95 36 64
Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-99. Anesthesiology 2004; 101:
950–9.
Pitkänen MT, Aromaa U, Cozanitis DA, Förster JG. Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to
2009. Acta Anaesthesiol Scand 2013;57:553-64.
Lagerkranser M. Neuraxial blocks and spinal haematoma. Part 1: Demographics and risk factors. Scand J Pain 2017;15:118-29.
GENDER RATIO AMONG NON-OBSTETRIC CASES

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Risk factors for spinal hematoma, Review of 166 cases published 1994 – 2015
• Patient related (conditions like spinal, liver, kidney
or haemostatic disorders) 50
• Procedure related (complicated blocks, esp. “bloody tap”) 51
• Drug related (platelet inhibitors, anticoagulants) 98
• No risk factor 24
Several cases with multiple risk factors
Lagerkranser M. Neuraxial blocks and spinal haematoma. Part 1: Demographics and risk factors. Scand J Pain 2017;15:118-29.
NEURAXIAL BLOCKS AND SPINAL HAEMATOMA

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Most commonly reported drugs, no of cases and (percentage)
• Low Molecular weight Heparin (LMH) 50 (31)
• Un-Fractionated Heparin (UFH) 39 (24)
• Acetyl-Salicylic Acid (ASA, Aspirin) 25 (16)
• Vitamin-K Antagonists (VKA) 17 (11)
• Non Steroidal Anti-Inflammatory Drugs (NSAID) 17 (11)
• ADP receptor inhibitors 4 (2.5)
• Fibrinolytics 4 (2.5)
• Direct acting Oral Anti-Coagulant (DOAC) 3 (1.9)
• Others 12
NEURAXIAL BLOCKS AND SPINAL HAEMATOMA

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• A successive increase in the prescription of antihaemostatic drugs and
intensified focus postoperative thromboprophylaxis with LMH, leading to
increased risk of post-CNB SH
• First warning came 1998: a cluster of SH, mainly in women, caused by
high dose perioperative LMH (enoxaparin in particular) reported by FDA
(black box warning)
• In order to reduce the risk of SH, the first international guidelines were
issued in 1998 by ASRA
GUIDELINES

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• Guidelines recommend the interval between the last dose of an
antihaemostatic drug and the procedure.
(CNB puncture or catheter removal/adjustment).
• This interval is generally based on multiples of elimination half life (T1/2),
which give a rough estimate of residual drug effect.
• For platelet inhibitors with irreversible effect, the interval is to a higher
degree determined by the regeneration rate of new platelets.
• The recommended intervals should not be significantly exceeded other than
for special reasons.
• When the drug is discontinued, the bleeding risk decreases BUT also the patient’s protection against a
new thrombotic event.
GUIDELINES

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GUIDELINES
• Guidelines also recommend the interval between a CNB procedure
(puncture or catheter manipulation/removal) to next dose of an
antihaemostatic drug.
• This interval is generally based on the time for a stable clot to be
established (approximately 8 h) and the time to peak effect of a drug
(Tmax), i.e. 8 h – Tmax.

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Drug Antiheamostatic target
site
Antiheamostatic
effect
Tmax T1/2 Time to % recovery of
platelets
ASA, low dose COX-1 irreversible + 1 h 0.5 h1 50% 3d 100% 7-10d
NSAIDs COX-1 reversible (+) Varies 1-72 h Varies
Clopidogrel ADPr, irreversible ++ 3-4 d2 1-2 h1 50% 3d * 100% 7d*
Prasugrel ADPr, irreversible +++ 1 h 2 h1 50% 5-6d* 100% 9d*
Ticagrelor ADPr, reversible +++ 2.5 h 7-8.5 h 50% 3d 100% 5d
Tmax = time to peak effect, T1/2 = plasma half life
1. Duration of antihaemostatic effects of irreversible inhibitors is more dependent on platelet regeneration rate than drug half-life.
2. Four hours with a loading dose of clopidogrel (300 mg).
*Data from Price et al, J Am Coll Cardiol 2012; 59:2338-43
Breivk H, Norum H, Fenger-Eriksen C, Alahuhta S, Vigfússon G, Thomas O, Lagerkranser M. Reducing risk of spinal haematoma from spinal and
epidural pain procedures. Scand J Pain 2018;18:129-50

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Drug Antiheamostatic target
factors
Tmax
hours
T1/2
hours
Renal
elimination
Heparin (UFH) II and Xa (1:1) <0.5 1-2 +
Dalteparin (LMH) II and Xa (1:3) 3-4 4 +
Enoxaparin (LMH) II and Xa (1:3) 3-4 4-7* ++
Tinzaparin (LMH) II and Xa (1:3) 3-4 4 +
VKA (e,g, warfarin) II, VII, IX, X 120 Vary 0
Rating: + = low, ++ = moderate, +++ = pronounced, ++++ = high.
Breivk H, Norum H, Fenger-Eriksen C, Alahuhta S, Vigfússon G, Thomas O, Lagerkranser M. Reducing risk of spinal haematoma from spinal and epidural pain
procedures. Scand J Pain 2018;18:129-50

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• Gogarten W, Vandermeuelen E, Van Aken H, Kozek S , Llau JV, Samama CM.
Regional anaesthesia and antithrombotic agents: recommendations of the European Society of
Anaesthesiology. Eur J Anaesth 2010;27:999-1015
• Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT.
Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. American Society of
Regional Anesthesia and Pain Medicine evidence-based guidelines (fourth edition). Reg Anesth Pain Med
2018;43:263–309
• Breivik H, Norum H, Fenger-Eriksen C, Alahuhta S, Vigfússon G, Thomas O, Lagerkranser M.
Reducing risk of spinal haematoma from spinal and epidural pain procedures. Scand J Pain 2018;18:129-50
(Update from 2010 Nordic guidelines)
• There are also specific guidelines issued for obstetric anaesthesia, and for spinal cord stimulation.
GUIDELINES

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Time from last dose until puncture or catheter manipulation/removal
GUIDELINES FOR NEURAXIAL BLOCKS
PLATELET INHIBITORS
Drug ESA 2010 ASRA 2018 Scandinavia 2018
Irreversible inhibitors
ASA None None 12 h1
Clopidogrel 7 d 7 d 5 d
Prasugrel 7-10 d 7-10 d 7 d
Reversible inhibitors
NSAID (non-selective) None None 12 h – 14 d1,2
Ticagrelor 5 d 5 -7 d 5 d
1 No interval in emergency cases
2 Depending on T1/2, with most NSAIDs <24 h

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GUIDELINES FOR NEURAXIAL BLOCKS
ANTICOAGULANTS
Drug ESA 2010 ASRA 2018 Scandinavia 2018
Parenteral anticoagulants
UFH (≤15000 U/d) 4-6 h 4-6 h 4-6 h
LMH (prophylactic) 12 h 12 h 10-12 h
LMH (for treatment) 24 h 24 h 24 h
Oral anticoagulants
VKA (warfarin)1 INR ≤ 1.4 5 d, normalised INR INR ≤ 1.42
Dabigatran Contraindicated 3-5 d3 2-5 d3
Rivaroxaban 22-26 h4 3 d 2 d
Apixaban 26-30 h4 3 d 2 d
1 Bridgeing with LMH required when INR <2 in patients with high thromboembolic risk
2 Higher INR allowed if there is a strong indication for the CNB
3 Interval depending on kidney function
4 For prophylaxis

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GUIDELINES FOR NEURAXIAL BLOCKS
ANTICOAGULANTS
Time from puncture or catheter manipulation/removal to next dose
Drug ESA 2010 ASRA 2018 Scandinavia 2018
Parenteral anticoagulants
UFH (≤15000 U/d) 1 h 1 h 1 h
LMH (prophylactic) 4 h 12 h/4 h1 2-6 h2
LMH (for treatment) 4 h 24 h 2-6 h2
Oral anticoagulants
VKA (warfarin) 0 h 0 h 0 h
Dabigatran3 6 h 6 h 24 h
Rivaroxaban3 4-6 h 6 h 24 h
Apixaban3 4-6 h 6 h 24 h
1 12 h after needle/catheter placement, 4 h after catheter removal
2 6 h in general, shorter if thromboembolic risk is high
3 DOACs are contraindicated in patients with an indwelling catheter

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• Give LMH in the evening
• Remove the catheter the following morning, >12 h later
• Be observant for any sign of a developing spinal haematoma
• If no such sign: repeat LMH in the evening (>6 h after removal)
PLAN FOR CATHETER REMOVAL

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HOW TO REDUCE THE RISK
• A careful history of bleeding tendency, bruising,
family history, anti-thrombotic drugs etc., and
standard tests in selected cases (platelet count, INR
and aPTT) are quite adequate.
• Avoid the combination of two or more
antihaemostatic drugs (e.g. LMH + NSAID) before
catheter removal.
• Check platelet count after 4 days of UFH or LMH
administration in order to exclude (or detect) HIT

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• Spinal haematoma is a serious complication after CNB.
• Although the risk is low, it is higher among elderly women and in patients
with any kind of risk factor.
• The number of patients at elevated risk has increased over time, especially
among elderly, mainly because of increased prescription of oral
antithrombotic drugs, and intensified postoperative thromboprophylaxis.
• Guidelines for the management of patients on antithrombotic medication
have been issued in many countries, and internationally, in order to
reduce this risk.
CONCLUSION

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• Although adherence to guidelines reduces the risk of SH, they are no
guarantee against such an event to occur.
• The consequence of a SH is often catastrophic (permanent paraplegia), and
the least sign of a developing haematoma (new back- or leg pain, often
radiating, leg weakness) calls for immediate action:
Arrange for an urgent MRI
Consult a neuro- or orthopaedic surgeon
Try to evacuate blood via the epidural catheter.
• Immediate surgical evacuation of the haematoma is indicated in most cases
with neurological deficits, while those with receding or milder symptoms
(pain only) may be treated in a conservative manner under close
surveillance.

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