Discussing the ASRA Guidelines for Anticoagulation and Antithrombotics during Regional Anesthesia including the considerations for neuraxial anesthesia and deep blocks. We also discuss the use of the ASRA Coags app. Question and Answer included.

1. ANTICOAGULATION AND
REGIONAL ANESTHESIA
Rajnish K. Gupta, MD
Associate Professor of Anesthesiology
Vanderbilt University Medical Center
May 11, 2020
@dr_rajgupta

2. Disclosures
• I am a lead developer on the ASRA Coags iOS and Android apps
• The department receives royalties on sale of the app
• I don’t personally receive any royalties
@dr_rajgupta

3. @dr_rajgupta

4. Do you ever do spinals or epidurals in your
practice?
A. Yes
B. No
C. I watch a lot of them
D. I do general for everything!
@dr_rajgupta

5. @dr_rajgupta

6. @dr_rajgupta

7. **Proceeds from sales of the app go to ASRA and Vanderbilt.
I have no personal monetary gain from app sales.**
@dr_rajgupta

8. @dr_rajgupta

9. A42-year-oldotherwisehealthy,whitefemalewithuterinecancerispresentingfora
totalabdominalhysterectomy. Youhaveplannedtoplacealow-thoracicepiduralfor
postoperativepaincontrol. Shehasbeenreceivingheparin5000unitssubcutaneously
twiceaday. Sheisonnootheranticoagulationoranti-plateletmedications. Thelast
doseofheparinwasgiven2hoursago. Howlongshouldyounormallywaitbefore
placementofanepidural?
A. 1 hour after last dose
B. 2 hours after last dose
C. 4-6 hours after last dose
D. No contraindication to
placing epidural
immediately
@dr_rajgupta

10. Heparin – SQ BID and TID
• Heparin binds to Antithrombin III and affects the function of
Factors IXa, Xa, VIIa, and primarily Thrombin
• Elevated PTT levels in some patients
even at 5000 IU dose
• Combining with recommendations from
European societies
• BID and TID recommendations combined
• Simplifies timing concerns regardless of
dosing schedule
@dr_rajgupta

11. Heparin – SQ BID and TID
• Before Neuraxial Procedure
Hold for 4 hrs (Ideally 6)
• Restart Medication after Procedure
Start immediately (peak effect is 2 hours after dose)
• Before Removing Catheter
Hold for 4 hrs (Ideally 6)
• Restart Medication after Removal
Start immediately (peak effect is 2 hours after dose)
@dr_rajgupta

12. A74year-oldAfricanAmericanmalecomestothepost-anesthesiacareunit
withalumbarepiduralafteralargelower-extremityfree-flapplasticsurgery
procedure. Theplanistoleavetheepiduralinplacefor3-4days. When
performingpost-operativepainrounds,younoticeanorderforenoxaparin
(Lovenox)40mgsubcutaneouslyevery24hours. Whatdoyoudo?
A. Give first dose enoxaparin the next
morning (at least 12 hrs postop);
epidural can be maintained
B. Explain your concern about safety
with surgical team; recommend
enoxaparin 30 mg SQ BID instead
C. Remove epidural immediately and
give next dose enoxaparin 12 hours
later
D. Give first dose of enoxaparin in
PACU; Epidural can be maintained
@dr_rajgupta

13. LMWH – Enoxaparin (Lovenox®)
• Multiple spinal hematomas related to LMWH
• Patient Factors – Female, >65, spinal column
pathology, renal insufficiency
• Anesthetic Factors – Trauma during
placement, Epidural procedure, indwelling
catheter
• Enoxaparin Dosing - <12 postop, <12 after
catheter removal (1 case), Twice daily dosing,
Concomitant antiplatelet or anticoagulant
medications, Higher dosing, Immediate
preop, intraop dosing
• With ATIII, inhibits Factor Xa
@dr_rajgupta

14. LMWH – Enoxaparin (Lovenox®)
• Twice Daily Dosing
• First dose the day following surgery, no less than 12 hrs after needle
placement
• Indwelling catheters must be removed before maintenance
prophylaxis
• Delay the first dose after catheter removal – 4 hrs
• Once Daily Dosing
• First dose 12 hrs after needle placement
• Second dose no sooner than 24 hrs after first dose
• Indwelling catheters removed 12 hrs after last dose
• Delay the first dose after catheter removal – 4 hrs
@dr_rajgupta

15. A68yomanscheduledfortotalhiparthroplastyforosteoarthritis. Hehasahistoryof
chronicpainandthesurgicalserviceplans forlumbarepiduralforpostoperativepain
relief. TheDVTprophylaxisplanistostartwarfarin5mgPOqhsonthenightbefore
surgery. Thepatienthasnotbeenonanticoagulationinthepast.Whenisthelatesttime
youcansafelypulltheepiduralcatheter?
A. In the PACU after surgery
B. First thing the next morning
C. The evening of POD1, INR is 1.3
D. The evening of POD1, INR is 1.7
@dr_rajgupta

16. Warfarin (Coumadin®)
• Effects Vit K-dependent factors
• You need about 40% of your
total factors for hemostasis
• Factor VII has the shortest half life
• Protein C & S (procoagulant) are
also Vit K-dependent but have
longer half-lives
• Initially patient is hypercoaguable
because of unopposed C&S levels
@dr_rajgupta

17. Warfarin (Coumadin®)
• Warfarin monitored by
measuring PT/INR
• PT/INR is very sensitive
to Factor VII levels
• Initiation of therapy may
show elevated INR (>1.5)
representing low VII
levels but all factors may
be >40%
• Total coagulation factors
don’t reach <40% until
about INR 1.9-2.0 on
initiation of warfarin
@dr_rajgupta

18. Warfarin (Coumadin®)
• Chronic Warfarin
• INR should be in normal levels before
Needle placement
• Ideally 4-5 days
• Initiation of Warfarin
• 2.5-5 mg takes 24-48 hrs to reach therapeutic
• If first dose before surgery  check INR 24 hrs later
• Daily INR while low dose warfarin given during catheter
• Safe to maintain catheter with INR <1.5
• INR 1.5 – 3  continue catheter with caution!
• Likely safe to pull catheter with INR < 2.0 for warfarin initiation therapy, since
INR elevated due to low Factor VII levels but total factor level >40%
Factor Half-life (hr)
II 50-80
VII 8
IX 24
X 25-60
@dr_rajgupta

19. A66year-oldwhitemalepresentsonthemorningofsurgeryforatotalhip
arthroplastyandyouplantoplacealumbarplexuscatheter. Hehadadrug-
elutingstentplaced12monthsagoforwhichhehasbeencontinuedon
clopidogrel(Plavix). Howlongshouldhebeoffhisclopidogrelpriorto
placementoftheblock?
A. Doesn’t need to stop
B. 5-7 days
C. 10 days
D. 14 days
@dr_rajgupta

20. Neuraxial vs Deep blocks
• Can you see the bleeding?
• Can you control the bleeding?
Apply pressure?
• Examples:
• Paravertebral blocks
• Lumbar plexus/
psoas compartment blocks
• Supraclavicular?
• Infraclavicular?
• Sciatic?
@dr_rajgupta

21. ADP
Receptor
@dr_rajgupta

22. Anti-Platelet therapy
Ticagrelor
Ticlopidine,
clopidogrel,
prasugrel
@dr_rajgupta

23. Ticlopidine (Ticlid®) & Clopidogrel (Plavix®)
• Thienopyridine Derivatives
• ADP antagonism  Inhibits platelet aggregation
•  Blocks GP IIb,/IIIa and fibrinogen interaction
• Reversible
• Normal Platelet aggregation 5-14 days after stopping
• Clopidogrel  5-7 days before Neuraxial block; Normalization of
platelet function should be documented between 5 and 7 days
• Ticlopidine  10 days (used to be 14 days)
Ticlopidine
Clopidogrel
@dr_rajgupta

24. Prasugrel (Effient®)
• Thienopyridine derivative
• Irreversibly Binds P2Y12 Receptor
• Prevents Platelet aggregation
• Indicated for Acute Coronary Syndrome patients
undergoing PCI
• Rapid onset  50% platelets effected in 1 hr, max
effect 2 hr
• Normal Platelet aggregation in 5-9 days
• Discontinue 7-10 days before Neuraxial procedure
Prasugrel
@dr_rajgupta

25. • Reversible ADP inhibitor (P2Y12
receptor antagonist)
• Rapid onset  Max effect 2 hours
• Indicated for Acute Coronary
Syndrome
• Usually given with Aspirin for
maintenance
• Normal Platelet aggregation in 5 days
• Discontinue 5-7 days before Neuraxial
procedure
Ticagrelor
Ticagrelor (Brilinta®)
@dr_rajgupta

26. A68yoFwithhistoryofstrokepresentsforthoracotomyforcarcinomaofthe
lung. Sheismaintainedondabigatran(Pradaxa)andpresentstothe
preoperativeclinicforevaluation. Thesurgeonshaverequestedathoracic
epiduralforherperioperativepaincontrol. Howlongdoessheneedtobeoff
herdabigatranpriortoepiduralplacement?
A. 7-10 days
B. 24 hours
C. 5 days
D. Does not need to be held
@dr_rajgupta

27. A78yomanisscheduledfortotalkneearthroplastyundergeneralanesthesia
andfemoralnervecatheter. Thesurgeonisplanningonusingrivaroxaban10
mgPOQdayforDVTprophylaxisstarting6-10hourspostopfor12days. How
longmusttherivaroxaban(Xarelto)beheldbeforethefemoralcathetercanbe
removedonPOD2?
A. 24 hours
B. 10 hours
C. 3 days
D. Does not need to be held.
@dr_rajgupta

28. A54yowomanwithhistoryofDVTssecondarytohormonetherapy,chronic
painsyndrome,andnewlydiagnosedbreastcancerpresentsforradicalleft
mastectomy. Theprimaryteamisplanningonusingaparavertebralcatheterto
assistwithpaincontrol. Sheismaintainedonapixaban(Eliquis)forherDVT
prophylaxispriortosurgery. Thesurgicalservicewantstoknowhowlongthe
apixabanmustbeheldbeforetheparavertebralcathetercanbeplaced?
A. 3 days
B. 24 hours
C. 7 days
D. Does not need to be held.
@dr_rajgupta

29. Coagulation Cascade
Apixaban
Rivaroxaban
Dabigatran
@dr_rajgupta

30. Dabigatran (Pradaxa®)
• Direct Thrombin inhibitor
• T1/2 = 12-17 hrs
• Discontinue 5 half lives in renally sufficient patient before
doing procedure  5 days
• Delay catheter removal 2 half lives  34-36 hrs
(this is only for unanticipated dabigatran administration in catheter patient,
not recommended for routine use with indwelling catheter)
• First dose after catheter removal, 8 hours minus time to max
effect  6 hrs
• Monitoring – Thrombin Time or Ecarin Time are only useful
monitors – must show NO activity
@dr_rajgupta

31. Rivaroxaban (Xarelto®)
• Factor Xa Inhibitor
• T1/2 = 11-13 hrs
• Discontinue 5 half lives in renally sufficient patient before
doing procedure  3 days
• Delay catheter removal 2 half lives  22-26 hrs
(this is only for unanticipated rivaroxaban administration in catheter patient,
not recommended for routine use with indwelling catheter)
• First dose after catheter removal, 8 hours minus time to max
effect  6 hrs
• Monitoring – Rivaroxaban level – must show NO level
@dr_rajgupta

32. Apixaban (Eliquis®)
• Factor Xa Inhibitor
• T1/2 = 10-15 hrs
• Discontinue 5 half lives in renally sufficient patient before
doing procedure  3 days
• Delay catheter removal 2 half lives  26-30 hrs
(this is only for unanticipated apixaban administration in catheter patient, not
recommended for routine use with indwelling catheter)
• First dose after catheter removal, 8 hours minus time to max
effect  6 hrs
• Monitoring – Anti-Xa Activity – must show NO activity
@dr_rajgupta

33. Did you use the app to answer the questions
even though I told you not to?
A. Yes
B. No
C. What app?
@dr_rajgupta

34. Clopidogrel
Ticlopidine
Prasugrel
Ticagrelor
Apixaban
Rivaroxaban
DabigatranWarfarin
Heparin (with ATIII)
Enoxaparin
@dr_rajgupta

35. @dr_rajgupta

36. @dr_rajgupta