This document discusses guidelines for performing neuraxial blocks in patients who require anticoagulation or antiplatelet therapy. It provides an overview of various anticoagulant and antiplatelet medications, including their mechanisms of action, dosages, and monitoring parameters. For each medication, recommendations are given on appropriate timing of neuraxial blocks or catheter removal in relation to the medication. The risks of spinal hematoma are also discussed. Overall, the document provides expert consensus guidelines on safely managing regional anesthesia for patients on various coagulation-altering medications.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Anticoagulants, antiplatelet drugs and anesthesiaRajesh Munigial
It is a presentation on anticoagulants and antiplatelets in anesthesia , starting from basis of coagulation , its tests and dugs and anesthetic implications
Based on latest ASRA (AMERICAN SOCIETY OF REGIONAL ANESTHESIA GUIDELINES)
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Anticoagulants, antiplatelet drugs and anesthesiaRajesh Munigial
It is a presentation on anticoagulants and antiplatelets in anesthesia , starting from basis of coagulation , its tests and dugs and anesthetic implications
Based on latest ASRA (AMERICAN SOCIETY OF REGIONAL ANESTHESIA GUIDELINES)
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
Erector spinae plane block is a relatively novel approach to pain management for a variety of surgical procedures. ESP block is a challenging anesthesia and analgesia technique that needs more research.
as an oral and maxillofacial surgeon, we should know how to manage a patient with known bleeding disorders in our regular practice to avoid unfortunate incidents
Oral Surgery in Patients on Anticoagulant TherapyVarun Mittal
Management of patients on Anticoagulant Therapy in Surgical Practice with special emphasis on Oral Surgical Procedures; along with Guidelines drawn from various Text Books and Journals
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. Improvement in patient outcomes,
including mortality and major morbidity
has been demonstrated with neuraxial
techniques, particularly with epidural
anesthesia and analgesia.
It is due to the attenuation of the
hypercoagulable response and the
associated reduction in the frequency of
thromboembolism.
3. Although this beneficial effect of neuraxial
techniques is recognized but the effect is
insufficient as the sole method of
thromboprophylaxis.
Consequently, anticoagulant, antiplatelet,
and thrombolytic medications have been
increasingly used in the prevention and
treatment of thromboembolism.
4. Long-term anticoagulation with warfarin
is often indicated for patients with a
history of VTE, mechanical heart valves,
and atrial fibrillation.
In addition, patients with bare metal or
drug-eluting coronary stents require
antiplatelet therapy with aspirin and
thienopyridine derivatives (e.g,
clopidogrel) for varying durations.
5. Coagulation defects are the principal risk
factors for regional anesthesia.
Spinal hematoma is a rare but potentially
devastating complication of regional
anesthesia.
Trauma to epidural veins in the presence of
coagulopathies may result in large
hematoma.
6. Definition: Symptomatic bleeding within the spinal
neuraxis
Actual incidence of spinal hematoma is unknown
Extensive literature search by M. Tryba (1993)
13 cases after 850,000 epidural anesthetics (<1:150,000)
7 cases after 650,000 spinal anesthetics (<1:220,000)
Study was prior to routine thromboprophylaxis
Recent epidemiologic surveys suggest the risk is higher
7. Patient with spinal hematoma presents
with severe back pain and neurological
deficit.
Diagnosis is confirmed by MRI.
Decompression laminectomy is required to
preserve neurologic functions.
Neuraxial blockade should be performed
cautiously in the presence of prophylactic
anticoagulation.
8. Pain management is based on appropriate
timings of needle placement and catheter
removal.
Clinician should have familiarity with
pharmacology of hemostasis altering drugs,
clinical studies as well as the case reports of
spinal hematoma.
9. Third Consensus Conference on Regional Anesthesia and Anticoagulation
As published in Regional Anesthesia and Pain Medicine, Vol 35, No 1,
January-February 2010, pp 64-101
10. Strength of Evidence
A: Randomized, clinical trials and meta-analyses
B: Observational and epidemiologic studies
C: Case reports and expert opinion
Grade of Recommendation
1: General agreement in efficacy
2: Conflicting evidence or opinion on the usefulness
3: General agreement that procedure is not useful
(and may be harmful)
14. Mechanism of action:
Interferes with the synthesis of Vit K
dependant clotting factors
1. II, VII, IX and X.
2. Anticoagulation of proteins C, and S.
15. Half life: 40 hours
Dosage: 2-15 mg / day
Monitoring: PT and INR
16. Caution should be made in performing
neuraxial block in patients recently
discontinued warfarin therapy.
The anticoagulant therapy must be
stopped (ideally 4 – 5 days before
performing the block).
Monitor PT/INR prior to initiation of the
block.
No Regional Anesthesia if in combination
of other drugs affecting the clotting.
17. If the first dose given 24 hrs earlier- check
PT/INR
Patients receiving warfarin during
epidural analgesia do PT/INR on daily
basis.
Check PT/INR before catheter removal if
initial doses of warfarin are given more
than 36 hours preoperatively.
Epidural catheters can be removed if INR
is < 1.5.
18. Neurological testing of motor and sensory
functions should be done.
Minimize the degree of motor and sensory
block.
If INR > 3, Hold warfarin
Reduced doses of warfarin in patients with
enhanced drug response.
20. Mechanism of action:
Accelerates the inactivation of factors IIa,
IXa, Xa, XIa, and XIIa by the serine protease
inhibitor, Antithorombin III (AT III).
21. Half life:1 to 1.5 hours.
Dose:
Bolus: 80 units / kg or 5000 units
Maintenance: 15 units / kg / hr or 700
to 2000 units / day
Monitoring: aPTT.
22. For mini dose prophylaxis :
No contraindication. Hold morning dose.
Check platelet count
23. In pts with combined neuraxial blocks and
intraoperative anticoagulation,
Avoid regional anesthesia with other
coagulopathies.
Avoid RA in patients with medications of
clotting inhibitors in combination.
Delay Heparin dose up to one hour after
needle placement.
24. Remove catheter 4 hours stopping the dose
and start the dose again after one hour.
Check for motor and sensory blockade.
Consider minimal dose of local anesthetics
for early detection of spinal hematoma.
25. Combining neuraxial techniques with full
anticoagulation of cardiac surgery
Insufficient data and experience to
determine the risk of hematoma.
Postoperative monitoring of neurological
functions.
Selection of solutions to minimize sensory
and motor blockade.
26. Mechanism of action: Inhibit clotting factor Xa
more than IIa.
Examples
Deltaparin
Enoxaparin
Tinzaparin
27. Half-life: Three to four times more than
Haparin
Doses:
Deltaparin: 2500-5000 u / day
Enoxaparin: 30-40 mg / day
Tinzaparin:175 u / day
28. Monitoring of anti – Xa level is not
recommended.
No RA in patients taking other clotting
inhibitors in addition.
In the presence of blood during needle and
catheter placement.
Delay LMWH therapy for 24 hours
Should be discussed with the surgeon.
29. Preoperative LMWH:
1. Thromboprophylaxis: Needle placement
should be delayed up to 10 – 12 hours.
2. Treatment doses: A delay of at least 24 hours
is recommended.
3. No RA if the dose is given in morning
preoperatively.
30. Postoperative LMWH: may undergo RA
technique, but removal of the catheter
depends upon total daily dose and
timing.
a. Twice daily dose:
increased risk of spinal hematoma.
First dose of LMWH should not be
administered 24 hours postoperatively.
Catheters should be removed prior to
initiation of thrombo-prophylaxis.
LMWH dose should be started after 2 hours
removing the catheter.
31. b. Single daily dose:
First dose should be administered 6 – 8 hours
postoperatively.
Second dose after 24 hours and catheters may be
safely maintained.
Catheters should be removed after 12 hours of last
LMWH dose.
LMWH dose can be started after two hours.
32. ASPIRIN and NSAIDS
Thienopyridine derivatives
Platelet GP IIb/IIIa antagonists
33. MECHANISM OF ACTION:
Blocks cyclooxygenase. Cyclooxygenase is
responsible for the production of
thromboxane A2 which inhibits platelet
aggregation and causes vasoconstriction.
DURATION OF ACTION:
Irreversible effect on platelets. Effect of
aspirin lasts for the life of the platelet which
is 7-10 days. Long term use of aspirin may
lead to a decrease in prothrombin production
and result in a lengthening of the PT.
34. MECHANISM OF ACTION:
Inhibits cyclooxygenase by decreasing tissue
prostaglandin synthesis.
DURATION OF ACTION:
Reversible. Duration of action depends on
the half life of the medication used and can
range from 1 hour to 3 days.
36. Either medication alone does not increase
risk.
Need to scrutinize dosages, duration of
therapy and concomitant medications
that may affect coagulation.
No wholly accepted laboratory tests. A
normal bleeding time does not indicate
normal homeostasis. An abnormal
bleeding time does not necessarily
indicate abnormal homeostasis.
37. History of bruising easily
History of excessive bleeding
Female gender
Increased age
39. MECHANISM OF ACTION:
Interfere with platelet membrane function
by inhibition of adenosine diphosphate (ADP)
induced platelet-fibrinogen binding.
DURATION OF ACTION:
Thienopyridine derivatives exert an
irreversible effect on platelet function for
the life of the platelet.
40. DC ticlopidine for 14 days prior to a neuraxial
block.
DC clopidogrel for 7 days prior to a neuraxial
block.
There is no accepted laboratory tests for
these medications.
42. Mechanism of action: Non peptide inhibitors
of GP IIb / IIIa receptor
Doses:
Abciximab. Dose:250 micrograms / kg
Eptifibatide. Dose:180 microgram / kg
Tirofiban. Dose: 10 micrograms / kg
43. No wholly accepted test including the
bleeding time.
Careful preoperative assessment is
necessary,
Easy bruisability
Excessive bleeding
Female gender
Increasing age
44. Platelet GIIb/IIIa Inhibitors:
RA should be avoided 2 days for abciximab and 4-
8 hours for eptifibatide and tirofiban therapy.
If administrated postoperatively following RA,
the patient should be monitored neurologically.
46. Although the plasma half life of thrombolytic drugs is
mainly hours, it may take days for the thrombolytic
effect to resolve.
47. No RA in the presence of these drugs.
In patients with catheters already in and
with sudden initiation of these drugs,
Neuraxial monitoring is necessary which should not be
more than 2 hour interval.
Infusion should be limited to drugs minimizing sensory
and motor blockade.
Fibrinogen level measurement.
No definite recommendation regarding the removal of
catheters.
48. Patients scheduled for thrombolytic therapy
must be inquired for history of neuroaxial
block.
Patients who received thrombolytic
therapy ,neuroaxial block is contraindicated,
no time interval is outlined.
49.
50. Antithrombotic medication for DVT
prophylaxis
Binds with antithrombin III which
neutralizes factor Xa.
Peak effect in 3 hours with half life of 17-
21 hours
Irreversible effect
Need further clinical experience to
formulate guidelines
Black box warning similar to the LMWH
51. Bivalirudin- thrombin inhibitor used in
interventional cardiology.
Lepirudin used to treat heparin-induced
thrombocytopenia.
Caution advised. No recommendations
related to limited clinical experience.
52. Dabigatran etexilate
Is a prodrug that inhibits both free and clot-
bound thrombin.
The drug is absorbed from the
gastrointestinal tract with a bioavailability of
5%.
The half-life is 8 hrs after a single dose and
up to 17 hrs after multiple doses.
Prolongs the aPTT
53. Rivaroxaban
Is a potent selective and reversible oral
activated factor Xa inhibitor.
Inhibition is maintained for 12 hrs.
Monitored with the PT, aPTT.
For Dabigatran etexilate and Rivaroxaban,
the lack of information regarding the
specifics of block performance and the
prolonged half-life warrants a cautious
approach.
54. For patients undergoing deep plexus or
peripheral block, recommendations regarding
neuraxial techniques, should also be applied
similarly.
55. In the absence of a large series of neuraxial
techniques in the pregnant population,
receiving prophylaxis or treatment of VTE,
ASRA guidelines (derived mainly from
surgical patients) should be applied to
parturient.
56. Garlic
Reduces blood pressure, thrombus formation, and serum
lipid and cholesterol levels
Inhibits in vivo platelet aggregation is dose-dependent
fashion
Time to normal hemostasis after discontinuation – 7 days
Ginkgo
Cognitive disorders, peripheral vascular disease, vertigo,
tinnitus, and altitude sickness
Inhibits platelet activating factor
Time to normal hemostasis after discontinuation – 36 hrs
Ginseng
Protects against effects of stress
May inhibit the coagulation cascade
Time to normal hemostasis after discontinuation – 24 hrs
These represent no added risk for spinal hematoma
57. These consensus statements represent the collective
experience of recognized experts in neuraxial
anesthesia and anticoagulation. They are based on
case reports, clinical series, pharmacology,
hematology, and risk factors for surgical bleeding.
Alternative anesthetic and analgesic techniques
should be used for the patients, who are at
unacceptable risk.
The patient's coagulation status should be optimized
at the time of spinal or epidural needle/catheter
placement, and the level of anticoagulation must be
carefully monitored during the period of epidural
catheterization.
58. Indwelling catheters should not be removed in
the presence of therapeutic anticoagulation
because this significantly increase the risk of
spinal hematoma.
Vigilance in monitoring is critical to allow early
evaluation of neurologic dysfunction and prompt
intervention.
Protocols must be in place for urgent magnetic
resonance imaging and hematoma evacuation if
there is a change in neurological status.
Editor's Notes
First, let’s go over the complication we are attempting to avoid…
This is the article we will be discussing today, published in Regional Anesthesia and Pain Medicine early this year. As you can see, the article is rather long, and filled with studies and literature that the group used to come up with their evidence-based recommendations. We will go over some of that literature today… some in more detail than others.
After each of the recommendations later in the presentation, you will see a grade consisting of a number and a letter. Before we get too far into it, I wanted to go over what these grades mean. Letters refer to the strength of evidence, while numbers refer to the general agreement. (Read the slide)