Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-based Guidelines (Fourth Edition)

Abstract

(Reg Anesth Pain Med. 2018;43:263–309) The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Fourth Consensus Conference on Regional Anesthesia and Anticoagulation in conjunction with the European Society of Anesthesiology (ESA) in response to emerging patient safety issues. Among these are the heightened risk of neuraxial bleeding due to increasingly potent antithrombotic medications, changing standards for venous thromboembolism (VTE) prevention, and conflicting recommendations by various bodies and societies. Spinal hematoma is an uncommon and catastrophic complication of epidural or spinal anesthesia. Previous versions of this report have been published in 1998, 2003 and 2010 as ASRA Consensus Documents. For this update, authors performed a systematic and general review of relevant literature published between 2010 and 2017. The members represented ASRA, ESA, and the Society for Obstetric Anesthesia and Perinatology (SOAP).

Direct oral anticoagulants: peri‐operative considerations and controversies

“…For example, a generally accepted cessation period before neuraxial anaesthesia in a patient with normal renal function is 4 days for dabigatran and 3 days for rivaroxaban, apixaban and edoxaban . Further comprehensive guidance is also available for patients undergoing regional anaesthesia . The recommendations from Erdoes et al are in broad agreement with published literature for patients presenting for elective major surgery.…”

Epidural blood patch for post-dural puncture headaches in adult and paediatric patients with malignancies: a review

“…52 Conventionally, an INR of 1.5 is a safe threshold for epidural placement. 53 Given the risks delineated here, it is imperative that a personalised approach be undertaken for each patient with PDPH in the setting of malignancy. The treatment team should weigh the severity of and debilitation caused by the headache, with the potential oncological, infectious, and haematological risks of the procedure.…”

Association of Lumbar Puncture With Spinal Hematoma in Patients With and Without Coagulopathy

“…Previous studies of risk of spinal hematoma following lumbar puncture primarily consist of case series of limited size. 3,[6][7][8]13 Two reports involving 941 children and 66 adults who had undergone lumbar punctures to treat acute leukemia 2.1-2.5 0/95 0 (0.00-3.81) 0/26 0 (0.00-13.2) 0/10 0 (0.00-30.8) 0/39 0 (0.00-9.03) 2.6-3.0 0/49 0 (0.00-7.25) 0/17 0 (0.00-19.5) 0/2 0 (0.00-84.2) 0/8 0 (0.00-36.9)…”