ESA- antitrombotic therapy


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ESA- antitrombotic therapy

  1. 1. 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
  2. 2. Spinal epidural haematoma in patients onantithrombotic drugsFirst 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
  3. 3. 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
  4. 4. The risk of haemorrhage ↓ spinal anaesthesia ↑epidural catether anaesthesia½ of all cases of bleeding occur during the removal of an epidural catether Regional anaesthesia and antithrombotic agents
  5. 5. 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 regimeGerman guidelines on thromboprophylaxis refer to preoperative administration only as an option, not as a requirement. Regional anaesthesia and antithrombotic agents
  6. 6. 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
  7. 7. Antithrombotic drugsHeparins - UFH, LMWHAnti-Xa agents - fondaparinux, idrabiotaparinux, rivaroxaban, apixaban, danaparoid Direct trombin inhibitors - desirudin, lepirudin, hirudin, argatrobanVitamin K antagonists - warfarin, fluindione, acenocoumarol, phenprocoumon Regional anaesthesia and antithrombotic agents
  8. 8. Antithrombotic drugsPlatelet aggregation inhibitors - acetylsalicylic acid, thienopyridines, clopidogrel, selective serotonin reuptake inhibitors, glycoprotein IIb/IIIa inhibitors (abciximab, tirofibam, eptifibatide Regional anaesthesia and antithrombotic agents
  9. 9. HeparinsBinds 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
  10. 10. Anti Xa agents inhibitorsFondaparinux - alternative anticoagulant in HIT  1/2 elimination 18h  36h before catether removal, and 12h between the next doseIdrabiotaparinux – 1/2 elimination 135h and up to 66 days  no data regarding neuraxial anesthesiaRivaroxaban - 22-26h between the last dose and catether withdrawal  next dose may be given after 4-6h Regional anaesthesia and antithrombotic agents
  11. 11. Direct trombin inhibitorsDesirudin, 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
  12. 12. Vitamin K antagonistswarfarin, fluindione, acenocoumarol, phenprocoumonII, VII, IX, X coagulation factorsnormalisation of INR → INR<1,4 ( Vit.K, PCC, FFP) Regional anaesthesia and antithrombotic agents
  13. 13. Platelet aggregation inhibitorsAcetylsalicylic 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 blockThienopyridines - irreversible antagonosing ADP at the platelets purine receptorsTiclopidine - neuraxial regional anesthesia should not be performed until 10 days elapsed between last ingestion and the procedureClopidrogel - 7 days after the last intake Regional anaesthesia and antithrombotic agents
  14. 14. 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
  15. 15. Platelet aggregation inhibitorsIf 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
  16. 16. HVALA!Regional anaesthesia and antithrombotic agents