The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine

Neal, Joseph M.; Barrington, Michael J.; Brull, Richard; Hadžić, Admir; Hebl, James R.; Horlocker, Terese T.; Huntoon, Marc A.; Kopp, Sandra L.; Rathmell, James P.; Watson, James C.

doi:10.1097/aap.0000000000000286

Cited by 391 publications

(272 citation statements)

References 191 publications

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“…There is no evidence for or an established role of DOAC monitoring to improve clinical outcomes in periprocedural settings. Finally, special care regarding these timelines for DOACs should also be taken in patients undergoing neuraxial anesthesia [51].…”

Section: The Perioperative Anticoagulant Use For Surgery Evaluation (mentioning

confidence: 99%

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

Spyropoulos

AlBadri²,

Sherwood

et al. 2016

Journal of Thrombosis and Haemostasis

161

144

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To cite this article: Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost 2016; 14: 875-85.Summary. The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.

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Section: The Perioperative Anticoagulant Use For Surgery Evaluation (mentioning

confidence: 99%

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

Spyropoulos

AlBadri²,

Sherwood

et al. 2016

Journal of Thrombosis and Haemostasis

161

144

View full text Add to dashboard Cite

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“…Lubrano et al [11] demonstrated a transient tubular dysfunction after induced hypotension with propofol and remifentanil (without concurrent adrenaline); however, a clear link to permanent renal dysfunction has not been demonstrated [17]. Specific concerns regarding spinal cord ischemia caused by prolonged periods of hypotension with neuraxial anesthetics is also well documented; studies have demonstrated a MAP of at least 60 mmHg is required to safely maintain spinal cord blood flow [14]. It must be stressed that these studies have reviewed standard neuraxial anesthesia with uncontrolled hypotension.…”

Section: Discussionmentioning

confidence: 99%

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Freeman

Thorne

Gaston

et al. 2017

Clinical Orthopaedics &Amp; Related Research

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Background Resection of pelvic and sacral tumors can cause severe blood loss, complications, and even postoperative death. Hypotensive epidural anesthesia has been used to mitigate blood loss after elective arthroplasty, but to our knowledge, it has not been studied as an approach that might make resection of pelvic and sacral tumors safer. Questions/purposes The purposes of this study were (1) to compare the blood loss and blood product use for patients undergoing pelvic and sacral tumor surgery under standard anesthesia or hypotensive epidural anesthesia; (2) to assess the frequency of end-organ damage with the two techniques; and (3) to compare 90-day mortality between the two techniques. Methods Between 2000 and 2014, 285 major pelvic and sacral resections were performed at one center. A total of 174 (61%) had complete data sets for analysis of blood loss, transfusion use, complications, and mortality at 90 days. Of those, 102 (59%) underwent hypotensive epidural anesthesia, whereas the remainder received standard anesthetic care. The anesthetic approach was determined by the anesthetists in charge of the case with hypotensive epidural anesthesia exclusively performed by one of two subspecialty trained anesthetists as their routine for major pelvic or sacral surgery. The groups were comparable in terms of potential confounding variables such as age, gender, tumor volume, and operation performed. Hypotensive epidural anesthesia was defined as a technique using an extensive epidural block up to T2-3 dermatome, peripherally administered low-concentration intravenous adrenaline infusion, and using unimpeded spontaneous respiration to achieve controlled hypotension, precise rate control of the heart, and enhanced velocity of venous return, all aggregated thus to minimize blood loss during pelvic surgery while preserving vital perfusion. The groups were assessed for perioperative blood loss calculated from pre-and postsurgery hemoglobin and transfusion use as well as postoperative complications, morbidity, and mortality at 90 days. Results There was less mean blood loss in the hypotensive epidural anesthesia group (1457 mL, SD 1721, 95% confidence interval [CI], 1114-1801 versus 2421 mL, SD 2297, 95% CI, 1877-2965; p = 0.003). Patients in the hypotensive epidural anesthesia group on average received fewer packed red cell transfusions (2.7 units, SD 2.9, 95% CI, 2.1-3.2 versus 3.9 units, SD 4.4, 95% CI, 2.9-5.0; Each author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all in...

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Section: Anaesthesia and Peripheral Nerve Injurymentioning

confidence: 99%

“…Studies mentioned that the risk of spinal haematoma is higher with epidural anaesthesia compared to spinal anaesthesia [57]. The risk is higher in patients who have coagulation abnormalities, advanced age, female gender, concurrent spinal stenosis or preexisting neurological diseases [58].Improper positioning is another cause of anaesthesia-related perioperative peripheral nerve injury. Wrong patient positioning increases the compression pressure on nerves which are superficial or in close proximity to a bone.…”

mentioning

confidence: 99%

Peripheral Nerve Injury and Current Treatment Strategies

Tezcan¹

2017

Peripheral Nerve Regeneration - From Surgery to New Therapeutic Approaches Including Biomaterials and Cell-Based Therapies Deve

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Neuronal cells are the main fundamental anatomic unit of the system. Nerve injuries are generally divided into three categories as neuropraxia, axonotmesis and neurotmesis. Neurotmesis is the most severe form. Schwann cells are activated within 24 hours of the injury and the healing cascade continued with the cells, which are stimulated by Schwann cells. And neurotrophic factors like nerve growth factor (NGF) have a crucial role in regeneration and degeneration processes. Additionally, Schwann cells upregulate the expression of some proteins, such as fibronectin, which are crucial for axonal regeneration. All this information about nerve healing sheds light on treatment studies. Iatrogenic nerve injury has an important place in peripheral nerve injury. Causes may be direct surgical damage, wrong intraoperative patient positioning, anaesthesiarelated reasons or limb tourniquets. Typical symptoms are motor or sensory deficits such as paraesthesia, weakness, paralysis and pain. Many of the traumatic nerve injuries require surgical repair. Direct nerve repair and autologous nerve grafts are still goldstandard treatment options. Additionally, nerve conduits are very successful to provide an ideal peripheral support for neuronal recovery but are still insufficient. In recent years, research efforts have focused on the neurotrophic factors and cell-based therapies to perform better microenvironment for neuronal healing.Keywords: peripheral nerve, injury, iatrogenic, nerve grafts, conduit, cell-based therapy IntroductionAn injury to a nerve can result in a problem with the muscle innervation or in a loss of sensation. In some people, it can also cause pain. The type of nerve injury will determine the type of treatment that will be needed. Peripheral nerve injuries (PNIs) affect all age groups and have many causes like trauma and medical disorders. The majority of the peripheral nerve injuries © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.(PNI) occur in the upper extremity and are secondary to trauma [1]. Typical symptoms are motor or sensory deficits such as paraesthesia, weakness, paralysis and pain [2]. Many of the traumatic nerve injuries require surgical repair. The primary goal of the repair is to achieve the reinnervation of the target organs, but the therapeutic options which are used at present cannot achieve perfect sensory and motor recovery in all cases. In this chapter, the pathophysiology and mechanisms of nerve injuries, the traumatic nerve injuries, especially the iatrogenic forms, and therapeutic options for the peripheral nerve injuries will be discussed. Peripheral nerve anatomyPeripheral nervous system consists of neuronal cells, glial cells and stromal cells. Neuronal cells are the main fundamental anatomic unit of the system. Neurons conduct elec...

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The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine

Cited by 391 publications

References 191 publications

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

Hypotensive Epidural Anesthesia Reduces Blood Loss in Pelvic and Sacral Bone Tumor Resections

Peripheral Nerve Injury and Current Treatment Strategies

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