Clotting-Factor Concentrations 5 Days After Discontinuation of Warfarin

Benzon, Honorio T.; Asher, Yogen; Kendall, Mark C.; Vida, Loyda N.; McCarthy, Robert J.

doi:10.1097/aap.0000000000000782

Cited by 7 publications

(10 citation statements)

References 19 publications

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“…23,24 In contrast, in VKA treated patients, an INR of at least 1.3 may be associated with factor activity levels less than 40% and disturbed coagulation. 5 Recent data from retrospective studies found that an INR range of at least 1.0 to 1.25 after major orthopaedic surgery or 1.0 to 1.49 after major general surgery increased the occurrence of major surgical bleeding. 6,25,26 Similar results were reported after cholecystectomy, 27 wherein the bleeding frequency predominantly increased in the presence of an INR of at least 1.5.…”

Section: Discussionmentioning

confidence: 99%

Regional anaesthesia in patients on antithrombotic drugs

Kietaibl

Ferrandis

Godiér

et al. 2022

European Journal of Anaesthesiology

142

103

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BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.

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Section: Discussionmentioning

confidence: 99%

Regional anaesthesia in patients on antithrombotic drugs

Kietaibl

Ferrandis

Godiér

et al. 2022

European Journal of Anaesthesiology

142

103

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“…Benzon et al, studied the remaining anticoagulation effect of warfarin five days after its discontinuation. In the majority of patients (n = 21), the international normalized ratio (INR) normalized to less than 1.2, which was considered adequate for safe neuraxial procedures 164 . A small number of patients (n = 2) had INR values of 1.3 or 1.4.…”

Section: - What Is the Optimal Protocol For Management Of Patients Wh...mentioning

confidence: 99%

“…A small number of patients (n = 2) had INR values of 1.3 or 1.4. However, the safety of this INR range for neuraxial injections was considered inconclusive 164 . Narouze et al, and the American Society of Regional Anesthesia (ASRA) published guidelines recommending stopping warfarin five to six days before interventional spine and pain procedures, with a goal INR of 1.4 or less 165 .…”

Section: - What Is the Optimal Protocol For Management Of Patients Wh...mentioning

confidence: 99%

Recommendations from the ICM-VTE: Spine

2022

Journal of Bone and Joint Surgery

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The ICM-VTE Spine Delegates* 1 -Is routine screening for DVT required in the preoperative and/or post-operative period for patients undergoing spine procedures?Response/Recommendation: There is no role for routine screening for deep venous thrombosis (DVT) in patients undergoing spine procedures. Doppler ultrasonography surveillance may be considered in high-risk surgical patients including those who are older, with spine injury, personal history of VTE, malignancy, cervical spondylotic myelopathy (CSM), and/or non-ambulatory.Strength of Recommendation: Limited.Delegates vote: Agree 96.43% Disagree 3.57% Abstain 0.00% (Strong Consensus).Rationale: Venous thromboembolism (VTE) is a wellknown complication of major orthopaedic and spine surgeries. The reported incidence of VTE in patients undergoing spine surgery range from 0.29% -31% 1-3 . Moreover, the overall rates of pulmonary (PE) and associated fatality after spinal surgery are 1.38% and 0.34%, respectively [2][3][4][5] .Although contrast venography has been used for diagnosis of DVT, it is not suitable for the routine screening of asymptomatic patients due to potential complications, technical issues, expense, and invasiveness 6 . Similarly, the use of D-dimer, a byproduct of fibrinolysis 7 , as a screening tool lacked sensitivity and specificity in detecting VTE after hip arthroplasty [8][9][10][11][12] . Ultrasonography, on the other hand, has become the primary non-invasive method for investigating suspected DVT of the femoral and popliteal veins 9 . Standard ultrasound showed relatively high sensitivity (> 90%) for proximal or (around 60%) for below-the-knee DVT in a systematic review of diagnostic cohort studies 13 . Duplex ultrasonography (DUS) has also improved precision and efficiency in diagnosing DVT compared to most non-invasive techniques 14 . Furthermore, combined D-dimer and ultrasound screening in patients with acute spinal cord injury have improved the detection of VTE compared to D-dimer screening alone 15 .However, controversy remains regarding the use of routine screening for DVT in the perioperative period for patients undergoing spine procedures. We performed an extensive systematic review of all publications. A total of 26 articles that satisfied all inclusion criteria were selected for data extraction after full review. Information about these studies with respect to year of publication, level of evidence, number of patients, methods of screening, timing of screening, methods of prophylaxis, and incidence of VTE are summarized in Table I. Studies suggest against screening for patients undergoing spine surgery while others recognize that only patients at high risk may benefit. Based on the available literature, the risk factors for an increased risk of VTE in patients undergoing spine surgery may be seen in older patients, long periods of bedrest from paralysis and pain, high D-dimer level, longer duration of operation, intraoperative blood loss and transfusion, previous history of VTE, fracture, comorbid disease burden and tumor surgery...

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“…6 The ASRA further states that for neuraxial procedures, INR should be 1.4 or less; however, in patients whose warfarin was stopped for 5 to 6 days, the INR should be normalized to <1.2. Benzon et al 7 investigated the effect of warfarin on INR and clotting factors (II, VII, IX, X) 5 days after discontinuation of warfarin. Twenty-one patients were studied, and it was found that if INR < 1.2, the median clotting factor activity was >40% and considered adequate for neuraxial procedures.…”

Section: Warfarinmentioning

confidence: 99%

Anticoagulation and Spine Surgery

Porto

Wessell

Alvarado

et al. 2020

Global Spine Journal

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Study Design: Literature review. Objective: Preoperative management of therapeutic anticoagulation in spine surgery is critical to minimize risk of thromboembolic events yet prevent postsurgical complications. Limited research is available, and most guidelines are based on drug half-lives. We aim to clarify current guidelines and available evidence for safe practice of spine surgery in this patient population. Methods: A literature search in PubMed was done encompassing comprehensive search terms to locate published literature on anticoagulation and spine surgery. Predefined inclusion and exclusion criteria were applied and data extraction was performed. Results: A total of 17 articles met the final inclusion criteria. Of these, 12 articles were retrospective chart reviews, 3 were prospective observational studies, and 2 were systematic reviews. Current practice suggests holding warfarin until international normalized ratio <1.4, anti-Xa drugs for 48 to 72 hours, 12 to 24 hours for low-molecular-weight heparin, and 4 to 24 hours for heparin, before surgery. Antiplatelet agents can be stopped for 1 to 3 days prior to operation (81-500 mg) but must be stopped for 1 week for doses >1 g/d. For Plavix, 5 to 7 days of discontinuation advised to prevent complications. Conclusions: This review provides an overview of main anticoagulation agents seen in preoperative setting for spine patients. Although data is mixed and no true randomized control trials are available, there is growing evidence suggesting the aforementioned guidelines are needed to optimize anticoagulation in setting of spine surgery. Further studies are needed to elucidate risk of complications while operating under therapeutic levels of anticoagulation for a variety of comorbid conditions.

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Clotting-Factor Concentrations 5 Days After Discontinuation of Warfarin

Abstract: Based on 40% activity of CFs, patients with INRs of 1.2 or less can be considered to have adequate CFs to undergo neuraxial injections. The number of patients with an INR of 1.3 and 1.4 is too small to make conclusions.

Cited by 7 publications

References 19 publications

Regional anaesthesia in patients on antithrombotic drugs

Regional anaesthesia in patients on antithrombotic drugs

Recommendations from the ICM-VTE: Spine

Anticoagulation and Spine Surgery

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