1) Managing patients on anticoagulants who require regional anesthesia or peripheral nerve blocks is challenging due to the risk of bleeding complications like epidural hematomas. 2) Guidelines provide recommendations on interrupting anticoagulants prior to a procedure and resuming them postoperatively based on the drug's half-life, bleeding risk level, and type of block performed. 3) Vigilant monitoring for neurological symptoms is important to allow early diagnosis and treatment of hematomas, which have the best outcome if evacuated within 8-12 hours of onset.

1. THR IN PATIENTS ON
ANTICOAGULANTS
DR RANJITA ACHARYA
PROFESSOR
DEPT OF ANAESTHESIA AND CRITICAL CARE
IMS & SUM HOSPITAL, BHUBANESWAR
1

2. 2

3. 3

4. OUTLINE
• Introduction
• Management of patient on anticoagulant
• Regional anesthesia for patient on anticoagulant
• Take home message
4

5. INTRODUCTION
 The number of anticoagulants treated patients who are scheduled for elective
surgery is increasing continuously.
 Regional anesthesia is practiced more and more because of better patient
outcome and satisfaction.
 Recent introduction of the new anticoagulant agents may render the anaesthetic
management of these patients more challenging and complicated.
 Perioperative management of patient on anticoagulants and antiplatelet therapy
for surgery is always challenging problem.
 Because the risk of thromboembolic event during interruption of these drugs
need to be balanced against the risk for bleeding
5

6. What is the problem?
• Incidence of hematoma is higher in patient on anticoagulants
• 1:1,00,000 for spinal and 33:1,00,000 for epidural
• Focus not only on prevention of hematoma but
also on early detection and treatment
6

7. LITERATURE REVIEW
Spinal Epidural Hematoma after Spinal Anesthesia in a Patient Treated with Clopidogrel and Enoxaparin
Rainer J. Litz, M.D, Birgit Gottschlich, M.D, Sebastian N. Stehr, M.D ; December 2004, Vol. 101, 1467–1470.
Extensive retroperitoneal hematoma without neurologic deficit in two
patients who underwent lumbar plexus block and were later anticoagulated
Robert S Weller 1, J C Gerancher, James C Crews, Kenneth L Wade
2003 Feb;98(2):581-5
•. 2003 Feb;98(2):581-5
•. 2003 Feb;98(2):581-5
Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar
plexus block
S M Klein 1, F D'Ercole, R A Greengrass, D S Warner ; 1997 Dec;87(6):1576-9.
Spinal-epidural hematoma following epidural anesthesia in the presence of
antiplatelet and heparin therapy
R J Litz 1, M Hübler, T Koch, D M Albrecht ; 2001 Oct;95(4):1031-3.
7

8. 8

9.  Increased awareness of DVT
 Increased prophylaxis
 Increased use of anticoagulants
 Increased surgical patients with anti coagulants
9

10. Things to consider pre-procedure
for patients on anticoagulants
 What is perioperative bleeding risk?
 What is perioperative thromboembolic risk?
 Can the anticoagulants be continued?
 Can the anticoagulants be discontinued?
 Need bridging anticoagulants?
10

11. THRMBOSIS HEMORRHAGE
11

12. ESTIMATE THROMBOEMBOLIC RISK
12

13. ASA Practice Advisory 2010
13

14. RISK OF HEMORRHAGE
 Patient specific risk( HAS- BLED)
 Risk stratification for procedural bleed
- high risk bleeding risk procedures
- low/moderate bleeding risk procedures
- minimal bleeding risk procedures
14

15. Raw HAS-BLED score for assessment of bleeding risk
warfarin anticoagulation.
15

16. RISK STRATIFICATION FOR PROCEDURAL BLEED
HIGH BLEEDING
RISK
 Cardiac, intracranial,
spinal surgery
 Cancer surgery (tumor
resection)
 Major orthopedic surgery
 TURP, bladder resection
 Neuraxial anesthesia
INTERMEDIATE
BLEEDING RISK
 Abdominal hysterectomy
 Laparoscopic
cholecystectomy
 bronchoscopy
LOW RISK
 Minor dermatological
procedures
 Opthalmic
procedures(cataract)
 Minor dental procedures
 Pacemaker or
cardioverter device
implantation
16

17. COMMON ANTICOAGULANTS ENCOUNTERED IN
THE SURGICAL SETTING
 Oral anticoagulants
 Standard heparin/ LMWH
 NEW Anticoagulants
 Antiplatelet medications
 Herbal medications
17

18. COAGULATION
CASCADE
18

19. 19

20. FONDAPARINUX APIXABAN
EDOXABAN
RIVAROXABAN
DABIGATRAN
20

21. Case scenario…
• A 50yr female patient a known case of rheumatic heart disease since age of 17
• Had undergone a successful mitral and aortic valve replacement surgery 11yrs
before
• H/o of fall from height and had hip fracture
• She was scheduled for total hip replacement
• She was a known diabetic on insulin therapy
• Presently she could climb two flights of stairs without any
syncope, palpitation, fatigue, chest pain or breathlessness prior
to trauma
• She was receiving oral warfarin 2mg once daily.
21

22. • Physical examination revealed to be afebrile with an irregularly
irregular pulse 104beats/min, RR 16 Breaths/min, BP 160/80mmHg
• Her systemic examination unremarkable
• ECG- atrial fibrillation with HR OF 110/MIN
• ECHO – She had 54% EF. Normal functioning valve, no
paravalvular leak, absence of vegetation and clot.
• How to manage this patient?
22

23. WARFARIN
ASRA RECOMMENDATIONS
23

24.  Discontinue warfarin at least 5days before elective surgery with a target
INR of < 1.5
 Check INR one day pre-op
 If INR >1.5 administer vit K(Phytomenadion) 2mg orally
 Recheck INR on day of surgery
 Patients at high risk for thromboembolism
consider Bridging therapy
 No bridging necessary for patients at low risk for thrmboembolism
24

25. ASA Practice Advisory
2010
25

26. Bridging therapy
(preoperative period)
 Refers to administration of LMWH OR
IV UFH during cessation of warfarin
 LMWH or IV heparin is usually in therapeutic dosage
26

27. HEPARIN
ASRA RECOMMENDATIONS
27

28. 28

29. LMWH
ASRA RECOMMENDATIONS
29

30. Prophylactic vs Therapeutic LMWH
• PROPHYLACTIC
Enoxaparin : 20-40mg SC daily
Dalteparin : 2500-5000 units SC daily
• THERAPEUTIC
Enoxaparin : 1mg/kg by BD
Dalteparin : 200units/kg by SC daily
30

31. Preoperative LMWH
• Needle placement should occur at least 12 hours after a prophylactic LMWH dose.
• In patients receiving higher (therapeutic) doses of LMWH, we recommend delay of at
least 24 hours prior to needle/catheter placement (grade 1C).
31

32. Postoperative LMWH
Single daily prophylactic dosing :
• Recommended that the first postoperative LMWH dose should be administered at least
12 hours after needle/catheter placement.
• The second postoperative dose should occur no sooner than 24 hours after the first
dose. Indwelling neuraxial catheters do not represent increased risk and may be
maintained.
• The catheter should be removed 12 hours after the last dose of LMWH.
• Subsequent LMWH dosing should occur at least 4 hours after catheter removal. (1C)
32

33. Single or BID therapeutic dosing :
• Therapeutic-dose LMWH may be resumed 24 hours after non–high-bleeding risk
surgery and 48 to 72 hours after high-bleeding-risk surgery.
• Recommended that indwelling neuraxial catheters be removed 4 hours prior to the
first postoperative dose and at least 24 hours after needle/catheter placement,
whichever is greater
33

34. 34

35.  Antithrombotic medication for DVT prophylaxis, pulmonary embolism and as an alternate
anticoagulant in patients with HIT.
 Binds with antithrombin III which neutralizes factor Xa.
In neuraxial anesthesia:
a) Prophylactic dose (2.5mg) may be used postoperatively with atraumatic neuraxial anesthesia
If used, epidural catheter should be removed only after 36hrs of the last dose and the subsequent
dose administered only after 12hrs of removal.
b) Therapeutic dose (5 -10mg/day) contraindicated post operatively due to the risk of unpredictable
residual effect in the body.
 Suggested that neuraxial catheters 6 hours be removed prior to the first (postoperative) dose.
FONDAPARINUX 35

36. DIRECTTHROMBININHIBITORS
 Desirudin
 Bivalirudin
 Argatroban
 Neuraxial techniques are not recommended in patients taking argatroban or bivalirudin.
36

37. NOACs
37

38.  The drawback is lack of specific antidotes for anticoagulation reversal, but this is slowly
changing with the introduction of idarucizumab
38

39. Indications :
 Approved for prevention of venous thromboembolism after hip or knee
replacement surgery
 Treatment and secondary prevention of venous thromboembolism,
 Prevention of stroke in nonvalvular atrial fibrillation.
39

40. ORALTHROMBININHIBITORS
40

41. DABIGATRAN
– It is a new thrombin competitive reversible inhibitor orally administered.
– First new agent approved for the prevention of ischemic stroke in patients with
non-valvular atrial fibrillation
– Dabigatran is highly dependent (>80%) on renal excretion.
– Estimated CrCl tends to overestimate actual renal function. Furthermore, renal
function may be further impaired perioperatively.
41

42. 42
Interval from last
dose to
placement/removal
Interval from
placement /removal
to next dose
Notes
Thrombin
inhibitor
Dabigatran
CrCl>/=80ml/min:3days
CrCl>/=50to79ml/min:4da
ys
CrCl>/=30to49ml/min:5da
ys
CrCl<30 ml/min: avoid NA
Renal function Unknown:
5days
6 hours
Remove catheter
prior to first
postoperative dose
If unanticipated
administration of
dabigatran occurs
with catheter in
place, withhold
further doses and
wait 34-36 hrs to
remove catheter

43. • The Long-Term Multicenter Observational Study of Dabigatran Treatment
in Patients With Atrial Fibrillation Randomized Evaluation of Long-Term
Anticoagulant Therapy (RE-LY) Study
• Conclusions: During 2.3 years of continued treatment with dabigatran after RE-
LY, there was a higher rate of major bleeding with dabigatran 150 mg twice daily
in comparison with 110 mg, and similar rates of stroke and death.
43

44. Direct Xa inhibitors
44

45.  Rivaroxaban
 Apixaban
 Edoxaban
 Activity is directed against the active site of factor Xa
 Factor Xa inhibitors have been associated with fewer strokes and embolic
events, fewer intracranial hemorrhages, and lower all-cause mortality
compared with warfarin
45

46. Dose Prior to
neuraxial
blockade (hrs)
Catheter removal
prior to 1st dose(hrs)
With indwelling
catheter dose to be
held
Rivaroxaban 72 6 22-26hrs
apixaban 72 6 26-30hrs
Edoxaban 72 6 22-28hrs
betrixaban 72 5 72hrs
46

47. ANTIPLATELETS
47

48. 48

49. 49

50. • Impact of preoperative maintenance or interruption of aspirin on
thrombotic and bleeding events after elective non-cardiac surgery: the
multicentre, randomized, blinded, placebo-controlled, STRATAGEM trial
J Mantz 1, C M Samama, F Tubach
• Conclusions: In these at-risk patients undergoing elective non-cardiac surgery,
we did not find any difference in terms of occurrence of major thrombotic or
bleeding events between preoperative maintenance or interruption of aspirin
50

51. 51

52. 52

53. Cangrelor
– Newest drug in this group. It is the only one available for intravenous administration
– like ticagrelor, it changes the conformation of the P2Y12 receptor, resulting in
inhibition of ADP-induced platelet aggregation.
– It received FDA approval in 2015 for adult patients undergoing percutaneous
coronary intervention (PCI).
– Fastest onset of action (seconds), platelet function normalizes within 60 minutes
after drug discontinuation.
– This rapid onset may allow for bridging therapy in patients with drug-eluting stents
who require surgery.
53

54.  The risk of serious bleeding associated with neuraxial block performed or
maintained in the presence of residual cangrelor effect is unknown
 Based on the elimination half-life, we suggest that neuraxial techniques be
avoided for 3 hours after discontinuation of cangrelor. (2C).
 Suggest that neuraxial catheters be removed prior to reinstitution of cangrelor
therapy postoperatively. (2C)
 Suggest that the first postoperative dose of cangrelor be administered 8 hours
after neuraxial catheter removal. (2C)
54

55. https://www.ahajournals.org/
55

56. https://www.ahajournals.org/
56

57. ANESTHETIC MANAGEMENT OF THE PATIENT
UNDERGOING PLEXUS OR PERIPHERAL BLOCK
 Case reports of major bleeding occurring with psoas compartment and lumbar
sympathetic blocks
 Patients with neurological deficits had complete recovery in 6-12 months
 The key to this reversal was the fact that bleeding occurred in expandable and
compressible tissue as opposed to the non- expandable compartments associated with
neuraxial blockade.
57

58. Reports of complications with axillary, infraclavicular, supraclavicular and interscalene
blocks.
But they are very few
Risk lower with ultrasound guided blocks especially in trained hands
58

59. 59

60. EPIDURAL HEMATOMA
HOW TO
DIAGNOSIS AND TREAT
60

61. Signs and Symptoms of an Epidural
Hematoma
 Low back pain(sharp and radiating)
 Sensory and motor loss(numbness and tingling/motor
weakness long after block should have abated)
Bowel and/or bladder dysfunction
 Paraplegia
61

62. Diagnostic Testing
• MRI(Preferred)
• CT scan(may miss small hematomas)
• Myelogram
62

63. Treatment and Outcome
• Must be treated within 8-12 hrs. of onset of symptoms
• Emergency decompressive laminectomy with
hematoma evacuation
• Outcome is generally poor if treated late
63

64. Factors affecting recovery
• Size and location of the hematoma
• Speed of hematoma development
• Severity and nature of pre-existing neurological problem
64

65. 65

66. TAKE HOME MESSAGE
66

67. 1) These consensus statements represent the collective experience of recognized experts in
neuraxial anesthesia and anticoagulation
2) They are based on case reports, clinical series, pharmacology, hematology and risk factors
of surgical bleeding.
3) Alternative anesthetic and analgesic should be used for patients who are at unacceptable
risk
4) The patient’s coagulation status should be optimized at the time of spinal and epidural
needle/catheter placement and the level of anticoagulation must be carefully monitored
during the period of epidural catheterization
5) Indwelling catheter should not be removed in the presence of therapeutic anticoagulation
because this significantly increase the risk of spinal hematoma
6) Vigilance in monitoring is critical to allow early evaluation of neurological dysfunction and
prompt intervention
7) Protocol must be in place for urgent Magnetic resonance imaging and hematoma
evacuation if there is a change in neurological status
67

68. Patient on Anticoagulation For Regional Anesthesia Is
An Extra Burdon On Anesthetist
patient
surgeon
anesthesiologist
68

69. 69