The document summarizes the 2010 recommendations of the European Society of Anesthesiology on neuraxial anesthesia and antithrombotic drugs. It provides time intervals that should elapse between taking different antithrombotic medications and performing neuraxial blocks or catheter removals based on the half-lives of the drugs. It also discusses preoperative versus postoperative thromboprophylaxis and considerations for various classes of antithrombotic agents including heparins, anti-Xa agents, direct thrombin inhibitors, vitamin K antagonists, and platelet aggregation inhibitors.

1. Recommendations of the European Society of
Anesthesiology
Gogarten, 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. Spinal epidural haematoma in patients on
antithrombotic 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. HVALA!
Regional anaesthesia and antithrombotic agents