Determination of residual antiplatelet activity of clopidogrel before neuraxial injections

Benzon, Honorio T.; McCarthy, Robert J.; Benzon, Hubert A.; Kendall, Mark C.; Robak, S.; Lindholm, Paul F.; Kallas, Peter; Katz, Jeffrey A.

doi:10.1093/bja/aer298

Cited by 32 publications

(27 citation statements)

References 35 publications

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“…31,38,39 Accordingly, point-of-care tests may provide individualized therapy to reduce the risk of spinal bleeding and stent thrombosis. 13,24,31 Alternative Techniques for Pain Management Multimodal conservative pain management with intravenous and oral analgesia using opioids, nonsteroidal antiinflammatory agents, and/or acetaminophen is ideal if tolerated from a respiratory standpoint. Of the nonpharmacologic interventions, thoracic paravertebral catheters have improved pain and pulmonary function for patients with rib fractures.…”

Section: Risk Of Stent Thrombosis After Coronary Artery Stent Implantmentioning

confidence: 99%

Pain-associated Respiratory Failure in Chest Trauma

et al. 2013

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T he leading cause of death in young people is trauma. Chest trauma has high associated mortality, thus diagnosis and treatment need to be addressed early on presentation. 1 The incidence of rib fractures range from 10% to 26% in traumatic thoracic injury and the number of rib fractures independently predict patients' pulmonary morbidity and mortality.2 Numerous cardiopulmonary to neurologic causes such as tamponade, hemo-pneumothorax, and cervical spine injury can be implicated ( fig. 1). Severe respiratory distress can also result from breathing-dependent pain where parenteral opioids are often insufficient in addressing the pain and associated respiratory failure.3 epidural analgesia is associated with reduction in mortality for all patients with multiple rib fractures but is underused, in part due to the potential risks of epidural hematomas. 2,4 Variables that alter the risk of bleeding including age and sex, comorbidities such as diabetes and liver cirrhosis, severity of trauma and degree of resuscitation, and anticoagulation or antiplatelet therapy must also be considered.We describe a patient under clopidogrel therapy presenting to the intensive care unit (ICU) with severe respiratory distress that improved with epidural analgesia. We provide a discussion of the risks and benefits of neuraxial analgesia in patients presenting with rib-fracture pain-related respiratory failure. Case ReportA 79-yr-old man with a history of chronic obstructive pulmonary disease, bronchiectasis, coronary artery disease postplacement of bare-metal stent several years ago, hypertension, and diabetes was transferred to our hospital shortly after motor-vehicle collision. home medications were aspirin 325 mg, clopidogrel 75 mg per day (taken morning of accident), as well as inhaled tiotropium, inhaled fluticasone/ salmeterol, albuterol, isosorbide dinitrate, metformin, and simvastatin. On arrival, the patient was hemodynamically stable with pulse oximeter saturations of 94% on a nonrebreather mask with 60% inspired oxygen concentration. Computed tomography imaging revealed second to ninth anterior right rib fractures, fourth through ninth anterior left rib fractures, and posterior 10th and 11th left rib fractures, but without flail chest nor pneumothorax. A small left pleural effusion, left lung and lingular atelectasis, and minimal ground glass opacity in the right upper lobe, and a small right-lower lobe pulmonary contusion were shown ( fig. 2). The patient received 3 l lactated Ringer's solution before arriving in our ICU. his Injury Severity Score of 24 was primarily due to rib and lung injuries (16 points), then moderate head and surface injuries (4 points each).After admission to the surgical ICU, he developed increasing pain-related respiratory distress during the day. Tylenol was administered, and hydromorphone 0.2 mg intravenously produced somnolence, but minimal improvement of respiratory effort and pain. he had an electrocardiogram unremarkable for cardiac ischemia and negative cardiac isoenzymes and brain-natriuertic ...

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Section: Risk Of Stent Thrombosis After Coronary Artery Stent Implantmentioning

confidence: 99%

Pain-associated Respiratory Failure in Chest Trauma

et al. 2013

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“…Unfortunately, the 2 studies involved only a small number of patients. 187,188 Most pain procedures are elective, and clopidogrel should preferably be stopped for 7 days. In cases of SCS trial in patients at high risk of thromboembolic events, we recommend consultation with the treating physician and stopping clopidogrel for 5 days before the trial of SCS, keeping the trial to the minimum duration possible during which time the patient remains off clopidogrel.…”

Section: Summary Recommendations For Pde Inhibitorsmentioning

confidence: 99%

“…In these circumstances, where clopidogrel will be stopped only 5 days prior to the procedure, a platelet function test such as the VerifyNow P2Y12 assay or platelet mapping portion of the thromboelastograph should be considered whenever available. [188][189][190] This is to ensure adequate recovery of the platelets.…”

Section: Summary Recommendations For Pde Inhibitorsmentioning

confidence: 99%

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition)

Narouze

Benzon

Provenzano³

et al. 2017

Regional Anesthesia and Pain Medicine

118

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The American Society of Regional Anesthesia and Pain Medicine (ASRA) 2012 survey of meeting attendees showed that existing ASRA anticoagulation guidelines for regional anesthesia were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures. The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in 2015. Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines. The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. The latest evidence was sought through extensive database search strategies and the recommendations were evidence based when available and pharmacology driven otherwise. We could not provide strength and grading of these recommendations because there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations. This publication is intended as a living document to be updated periodically with consideration of new evidence.

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“…Unfortunately, the 2 studies involved only a small number of patients. 179,180 Most pain procedures are elective and clopidogrel should preferably be stopped for 7 days. In cases of SCS trial in patients at high risk for thromboembolic events, we recommend consultation with the treating physician and stopping clopidogrel for 5 days before the trial of SCS, keeping the trial to the minimum duration possible during which time the patient is still off clopidogrel.…”

Section: Summary Recommendations For Pde Inhibitorsmentioning

confidence: 99%

“…In these circumstances, where clopidogrel will be stopped only 5 days before the procedure, a platelet function test such as the VerifyNow P2Y12 assay or platelet mapping portion of the thrombelastograph should be considered whenever available. [180][181][182] Prasugrel is a prodrug similar to clopidogrel and also causes irreversible inhibition of the P2Y12 receptor. 183 Unlike clopidogrel, it requires only 1 metabolic step to form its active drug.…”

Section: Summary Recommendations For Pde Inhibitorsmentioning

confidence: 99%

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

Narouze

Benzon

Provenzano³

et al. 2015

Regional Anesthesia and Pain Medicine

267

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Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures. In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine. The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

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Determination of residual antiplatelet activity of clopidogrel before neuraxial injections

Abstract: These findings support the recommendation that discontinuation of clopidogrel for 5 days allows >70% of platelet function and might be adequate before a neuraxial injection is performed.

Cited by 32 publications

References 35 publications

Pain-associated Respiratory Failure in Chest Trauma

Pain-associated Respiratory Failure in Chest Trauma

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition)

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications

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