Epidural Hematoma Associated with Dextran Infusion

Muir, Jesse J.; Church, Eric J.; Weinmeister, Kent P.

doi:10.1097/01.smj.0000054723.61200.0a

Cited by 7 publications

(7 citation statements)

References 15 publications

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“…There are three case reports on post‐CNB SH in patients receiving dextran infusions, where other drugs could also have contributed: one with intraoperative heparinization in an isolated leg, 34 one with ASA and heparin, 107 and one with chronic prednisolone therapy 108 …”

mentioning

confidence: 99%

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Breivik

Bang

Jalonen

et al. 2009

Acta Anaesthesiol Scand

158

161

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mentioning

confidence: 99%

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Breivik

Bang

Jalonen

et al. 2009

Acta Anaesthesiol Scand

158

161

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“…There were only 3 reports of bleeding complications when anticoagulant therapy was continued for interventional techniques (176,177,388). However, there is an abundance of literature with complications related to anesthesia and surgery (209,(212)(213)(214)216,217,219,220,224,(226)(227)(228)230,242,248,253,258,259,262). Further, Manchikanti et al (81), in assessing the frequency of adverse effects during interventional pain management techniques, showed bleeding complications with epidural hematoma in 26 instances compared to 29 instances where antiplatelet and warfarin therapy was discontinued.…”

Section: Se277mentioning

confidence: 99%

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Atlantic

Manchikanti

Benyamin³

et al. 2013

Pain Phys

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Background: Interventional pain management is a specialty that utilizes invasive procedures to diagnose and treat chronic pain. Patients undergoing these treatments may be receiving exogenous anticoagulants and antithrombotics. Even though the risk of major bleeding is very small, the consequences can be catastrophic. However, the role of antithrombotic therapy for primary and secondary prevention of cardiovascular disease to decrease the incidence of acute cerebral and cardiovascular events is also crucial. Overall, there is a paucity of literature on the subject of bleeding risk in interventional pain management along with practice patterns and perioperative management of anticoagulant and anti-thrombotic therapy. Study Design: Best evidence synthesis. Objective: To critically appraise and synthesize the literature with assessment of the bleeding risk of interventional techniques including practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Methods: The available literature on the bleeding risk of interventional techniques and practice patterns and perioperative management of anticoagulant and antithrombotic therapy was reviewed. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 through December 2012 and manual searches of the bibliographies of known primary and review articles. Results: There is good evidence for the risk of thromboembolic phenomenon in patients who discontinue antithrombotic therapy, spontaneous epidural hematomas occur with or without traumatic injury in patients with or without anticoagulant therapy associated with stressors such as chiropractic manipulation, diving, and anatomic abnormalities such as ankylosing spondylitis, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. There is fair evidence that excessive bleeding, including epidural hematoma formation may occur with interventional techniques when antithrombotic therapy is continued, the risk of thromboembolic phenomenon is higher than the risk of epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques, to continue phosphodiesterase inhibitors (dipyridamole [Persantine], cilostazol [Pletal], and Aggrenox [aspirin and dipyridamole]), and that anatomic conditions such as spondylosis, ankylosing spondylitis and spinal stenosis, and procedures involving the cervical spine; multiple attempts; and large bore needles increase the risk of epidural hematoma; and rapid assessment and surgical or nonsurgical intervention to manage patients with epidural hematoma can avoid permanent neurological complications. There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy clopidogrel (Plavix), ticlopidine (Ticlid), or prasugrel (Effient) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa®) and rivaroxaban (Xarelto®) to discontinue to avoid bleeding and epidural hematomas during interventional techniques and to continue to avoid cerebrovascular and cardiovascular thromboembolic events. Recommendations: The recommendations derived from the comprehensive assessment of the literature and guidelines are to continue NSAIDs and low dose aspirin, and phosphodiesterase inhibitors (dipyridamole, cilostazol, Aggrenox) during interventional techniques. However, the recommendations for discontinuation of antiplatelet therapy with platelet aggregation inhibitors (clopidogrel, ticlopidine, prasugrel) is variable with clinical judgment to continue or discontinue based on the patient’s condition, the planned procedure, risk factors, and desires, and the cardiologist’s opinion. Low molecular weight heparin (LMWH) or unfractionated heparin may be discontinued 12 hours prior to performing interventional techniques. Warfarin should be discontinued or international normalized ratio (INR) be normalized to 1.4 or less for high risk procedures and 2 or less for low risk procedures based on risk factors. It is also recommended to discontinue Pradaxa for 24 hours for paravertebral interventional techniques in 2 to 4 days for epidural interventions in patients with normal renal function and for longer periods of time in patients with renal impairment, and to discontinue rivaroxaban for 24 hours prior to performing interventional techniques. Limitations: The paucity of the literature. Conclusion: Based on the available literature including guidelines, the recommendations in patients with antithrombotic therapy for therapy prior to interventional techniques are provided. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions

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“…This clinical effect occurs 2-8 hours after the infusion is started and depends on the dose and molecular size of dextran. Additionally, dextran reduces the level of factor VIII activator, which in turn, diminishes platelet adhesiveness and aggregation (110,111). The typical use is for venous thromboprophylaxis for general and orthopedic surgery (110).…”

Section: Dextranmentioning

confidence: 99%

“…Only one epidural hematoma, following a neuraxial procedure has been reported in a patient receiving dextran therapy (111).…”

Section: Dextranmentioning

confidence: 99%

“…7, No. 1,2004 abnormalities, the volumes used in epidural blood patches might not be tolerated (111). In fact, volumes as low as 5 cc of local anesthetic have caused epidural compression at T12-L1, cephalad to a pre-existing extradural compression at L3-4 disc herniation in a patient receiving an epidural steroid injection (400).…”

Section: Thoracic Lumbar Sacral Spinementioning

confidence: 99%

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Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature

Raj¹

2004

Pain Phys

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Epidural Hematoma Associated with Dextran Infusion

Cited by 7 publications

References 15 publications

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine

Assessment of Bleeding Risk of Interventional Techniques: A Best Evidence Synthesis of Practice Patterns and Perioperative Management of Anticoagulant and Antithrombotic Therapy

Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature

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