Anticlotting Drugs and Regional Anaesthesia-1

Coagulation Coagulation disorders and disorders and

Regional Regional AnaesthesiaAnaesthesiaDr. Manish SinghalDr. Manish Singhal

IntroductionIntroduction Clotting disorders could be drug related or disease Clotting disorders could be drug related or disease

relatedrelated

Wide use of anti-clotting drugs by patients Wide use of anti-clotting drugs by patients scheduled for surgeryscheduled for surgery

Challenge for Anaesthetists when considering Challenge for Anaesthetists when considering Regional Anaesthesia TechniqueRegional Anaesthesia Technique

Appropriate Management should be based on safety Appropriate Management should be based on safety intervals established according to the pharmacology intervals established according to the pharmacology of the drug and the regional techniqueof the drug and the regional technique

Guidelines published by various Anaesthesia Guidelines published by various Anaesthesia SocietiesSocieties

Incidence of Spinal Incidence of Spinal HaematomasHaematomas

Data on the incidence of spinal haematoma Data on the incidence of spinal haematoma following neuraxial blockade are mainly following neuraxial blockade are mainly based on audit studies and case reportsbased on audit studies and case reports

EpiduralEpidural Anaesthesia – 1 in 150 000Anaesthesia – 1 in 150 000 Spinal Anaesthesia –Spinal Anaesthesia – 1 in 220 0001 in 220 000 Spontaneous – 1 in 1000 000 patients per Spontaneous – 1 in 1000 000 patients per

yearyear

The administration of anticoagulants is The administration of anticoagulants is recognized as an important risk factor in the recognized as an important risk factor in the development of spinal haematoma. development of spinal haematoma.

Incidence of Spinal Incidence of Spinal HaematomasHaematomas

Vandermeulen and colleaguesVandermeulen and colleagues reviewed the reviewed the literature between 1906 and 1994 and reported literature between 1906 and 1994 and reported 61 61 casescases of spinal haematoma following spinal or of spinal haematoma following spinal or epidural anaesthesia.epidural anaesthesia.

In In 42 of these patients (68%)42 of these patients (68%) there was evidence of there was evidence of abnormal clotting:abnormal clotting:

2525 had received i.v. or s.c. had received i.v. or s.c. unfractionated unfractionated heparin or LMWHheparin or LMWH before or after neuraxial block. before or after neuraxial block.

5 5 had undergone vascular surgical procedures had undergone vascular surgical procedures and are presumed to have received and are presumed to have received intraoperative heparinintraoperative heparin..

1212 patients were being treated with either patients were being treated with either antiplatelet medication, dextran 70, oral antiplatelet medication, dextran 70, oral anticoagulants or thrombolyticsanticoagulants or thrombolytics immediately immediately before or after neuraxial blockade.before or after neuraxial blockade.

Clotting disordersClotting disorders

Haemostatic FailureHaemostatic FailureImpaired function of plateletsImpaired function of platelets,,((Leukemia, Cytotoxic drugs,Aplastic Leukemia, Cytotoxic drugs,Aplastic

Anaemia etcAnaemia etc..))Impaired function of blood vessels(Impaired function of blood vessels(Ehler-Danlos, Ehler-Danlos,

Marfan’s,Steroids,Vasculitis Marfan’s,Steroids,Vasculitis ....))Impaired function of coagulation Impaired function of coagulation pathways(pathways(haemophilia,Liver dis, DIChaemophilia,Liver dis, DIC))

Commonly encountered coagulation Commonly encountered coagulation disorders.disorders.Von Willebrand diseaseVon Willebrand diseaseITPITPHaemolytic uremic syndromeHaemolytic uremic syndromeHaemophiliaHaemophiliaDICDIC

Anticlotting Drugs that may Anticlotting Drugs that may interfere with regional anaesthesiainterfere with regional anaesthesia

Antiplatelet DrugsAntiplatelet Drugs

Low Molecular weight heparin Low Molecular weight heparin (LMWH)(LMWH)

Unfractioned heparin (UH)Unfractioned heparin (UH)

Oral anticoagulantsOral anticoagulants

Direct factor Xa inhibitorsDirect factor Xa inhibitors

Regional Anaesthesia Regional Anaesthesia Minimum Haemostatic Minimum Haemostatic

ConditionsConditions Functioning platelets ≥ 50,000 platelets Functioning platelets ≥ 50,000 platelets

/ml/ml

International normalized ratio (International normalized ratio (INRINR) ≤ ) ≤ 1.51.5

Activated prothrombin time (Activated prothrombin time (aPTTaPTT) ≤ ) ≤ 45s45s

(aPTT ratio ≤ 1.5)(aPTT ratio ≤ 1.5)

Regional Anaesthesia in patients on Regional Anaesthesia in patients on treatment with LMWHtreatment with LMWH

LMWH exert their anticoagulation activity by activation LMWH exert their anticoagulation activity by activation of antithrombin mediated by single sequence of of antithrombin mediated by single sequence of pentasaccharidepentasaccharide

Ratio of anti Xa/anti-IIa inhibition ranges, for the Ratio of anti Xa/anti-IIa inhibition ranges, for the different LMWH, between 2:1 and 8:1.different LMWH, between 2:1 and 8:1.

Following the subcutaneous (s.c.) administration of Following the subcutaneous (s.c.) administration of LMWH, the highest plasma levels are reached LMWH, the highest plasma levels are reached approximately after 4h, with their activity persisting approximately after 4h, with their activity persisting even 24h latereven 24h later

Characteristics of low molecular Characteristics of low molecular weight heparinsweight heparins

DrugsDrugs Half-life Half-life (min)(min)

Peak of Peak of action (h)action (h)

Ratio Ratio anti-Xa/aanti-Xa/a

nti-IIanti-IIa

ProphylactiProphylactic dose 24hc dose 24h

Therapeutic Therapeutic dosedose

EnoxaparEnoxaparinin

DaltepariDalteparinn

TinzapariTinzaparinn

129 – 180129 – 180

119 – 139119 – 139

9090

2 – 42 – 4

2.8 – 42.8 – 4

4 – 64 – 6

3.8 : 13.8 : 1

2.7 : 12.7 : 1

1.7 : 11.7 : 1

2000 – 2000 – 40004000**

2500 – 2500 – 50005000

3500 – 3500 – 45004500

100mg/kg/100mg/kg/12h12h****

100mg/kg/100mg/kg/12h12h

175mg/kg/175mg/kg/dayday

Doses in anti-Xa s.c. units for the prophylaxis or treatment of deep vein Doses in anti-Xa s.c. units for the prophylaxis or treatment of deep vein thrombosis and pulmonary thromboembolism.thrombosis and pulmonary thromboembolism.

** Equivalent to 20 – 40 mg;Equivalent to 20 – 40 mg;

**equivalent to 1 mg /kg/12h**equivalent to 1 mg /kg/12h

Recommendations for regional Recommendations for regional anaesthesia in patients receiving anaesthesia in patients receiving

LMWHLMWHSEDAR

ASRA DGAI OGARI BARA

Puncture with or without Puncture with or without catheter after:catheter after:

Prophylactic LMWHProphylactic LMWH

Therapeutic LMWHTherapeutic LMWH

LMWH following non-traumatic LMWH following non-traumatic puncture with or without puncture with or without cathetercatheter

Removal of the catheter Removal of the catheter following LMWHfollowing LMWH

LMWH following removal of the LMWH following removal of the cathetercatheter

12h12h

24h24h

6h6h

12h12h

6h6h

10 – 10 – 12h12h

24h24h

6–8h6–8h

10 – 10 – 12h12h

>2h>2h

10 –10 –12h12h

----

4h4h

12h12h

----

12h12h

24h24h

4h4h

----

----

12h12h

24h24h

4h4h

12h12h

>4h>4h

SEDARSEDAR: Sociedad Espanola de Anestesiologia y Reanimacion; : Sociedad Espanola de Anestesiologia y Reanimacion; ASRAASRA: American : American Society of Regional Anaesthesia; Society of Regional Anaesthesia; DGAIDGAI: Deutsche Gesellschaft fur Anaesthesiologie : Deutsche Gesellschaft fur Anaesthesiologie und Intensivmedizin; und Intensivmedizin; OGARIOGARI: Osterreichischen Gesellschaft fur Anasthesiologie und : Osterreichischen Gesellschaft fur Anasthesiologie und Intensivmedizin; Intensivmedizin; BARABARA: Belgian Association for Regional Anaesthesia; : Belgian Association for Regional Anaesthesia; LMWHLMWH: Low : Low molecular weight heparins.molecular weight heparins.

Comparison of the Comparison of the recommendationsrecommendations

No distinction is made in the safety period with regard to No distinction is made in the safety period with regard to the single spinal epidural shot or epidural catheter the single spinal epidural shot or epidural catheter insertioninsertion

In case of haemorrhagic puncture, safety period up to 24h. In case of haemorrhagic puncture, safety period up to 24h. However, this measure, which seeks to increase safety in However, this measure, which seeks to increase safety in terms of the development of a spinal haemorrhage, terms of the development of a spinal haemorrhage, underestimates the risk of development of DVTunderestimates the risk of development of DVT

Most controversial point pertains to the safety interval Most controversial point pertains to the safety interval necessary for the administration of LMWH following necessary for the administration of LMWH following removal of the catheter (SEDAR – conservative at 6h, ASRA removal of the catheter (SEDAR – conservative at 6h, ASRA – less demanding - at least 2h). SEDAR recommendation – less demanding - at least 2h). SEDAR recommendation has a 2-fold reason:has a 2-fold reason:

• SimplicitySimplicity of the overall recommendation (12h/6h) of the overall recommendation (12h/6h)

• Experience with published cases, where a greater Experience with published cases, where a greater number of number of spinal haematomas (more than 60%) were spinal haematomas (more than 60%) were produced through removal of the catheterproduced through removal of the catheter. Perceived to . Perceived to be the moment with greatest haemorrhagic risk, which be the moment with greatest haemorrhagic risk, which would justify the safety interval proposed by the SEDAR would justify the safety interval proposed by the SEDAR guideline.guideline.

Regional anaesthesia in patients Regional anaesthesia in patients receiving antiplatelet drugsreceiving antiplatelet drugs

Four Groups of antiplatelet drugsFour Groups of antiplatelet drugs

Adenosine diphosphate (ADP)Adenosine diphosphate (ADP) Thienopyridine compounds Thienopyridine compounds ticlopidine and clopidogrelticlopidine and clopidogrel. .

Activity peaks after 3-5 days, prolonged antiaggregant Activity peaks after 3-5 days, prolonged antiaggregant effect (7-10 days)effect (7-10 days)

GPIIb/IIIa receptor antagonistsGPIIb/IIIa receptor antagonists Abciximab, tirofiban and eptifibatideAbciximab, tirofiban and eptifibatide. More potent drugs . More potent drugs

but with a shorter-lasting antiaggregant effect(around 24h)but with a shorter-lasting antiaggregant effect(around 24h)

Compounds that increase the intraplatelet levels of cAMPCompounds that increase the intraplatelet levels of cAMP Prostacyclin or epoprostenolProstacyclin or epoprostenol (antiaggregant effect less than (antiaggregant effect less than

3h) and 3h) and dipyridamoledipyridamole (moderate antiaggregant effect (moderate antiaggregant effect lasting about 24h)lasting about 24h)

COX 1 inhibitorsCOX 1 inhibitors Acetylsalicylic acid (ASA) and trifusalAcetylsalicylic acid (ASA) and trifusal, whose effect last , whose effect last

throughout the life of the platelet (7 – 10 days)throughout the life of the platelet (7 – 10 days) NSAIDS – oxicams, indomethacin or ketorolacNSAIDS – oxicams, indomethacin or ketorolac. Blocking . Blocking

effect is reversibleeffect is reversible. .

Antiplatelet Therapy: TargetsAntiplatelet Therapy: Targets

CollagenCollagenThrombinThrombin

TXATXA22

ADPADP

(Fibrinogen(FibrinogenReceptor)Receptor)

ADP = adenosine diphosphate, TXAADP = adenosine diphosphate, TXA22 = thromboxane A = thromboxane A22, COX = cyclooxygenase, COX = cyclooxygenase

clopidogrel bisulfateclopidogrel bisulfate

TXATXA22

phosphodiesterasephosphodiesterase

ADPADP

Gp IIb/IIIaGp IIb/IIIa ActivationActivation

COXCOX

ticlopidine hydrochlorideticlopidine hydrochloride

aspirinaspirin

Gp 2b/3a InhibitorsGp 2b/3a Inhibitors

dipyridamoledipyridamole

Schafer AI. Am J Med 1996;101:199–209

Thienopyridine: Mechanism of ActionThienopyridine: Mechanism of Action

ADP / ATP

P2Y1P2X1 P2T12

Gi2 coupled

Gq coupled

Ca2+ Ca2+ cAMP

Platelet shape change Transient aggregation

No effect on fibrinogen receptor

Cation influx Calcium mobilization

Fibrinogen receptor activation

Thromboxane A2 generation

Sustained Aggregation ResponseSavi P et al. Biochem Biophys Res Commun 2001; 283:379–83 and Ferguson JJ. The Physiology of Normal Platelet Function. In: Ferguson JJ, Chronos N, Harrington RA (Eds). Antiplatelet Therapy in Clinical Practice. London: Martin Dunitz; 2000: pp.15–35.

Clopidogrel or Ticlopidine

Aspirin: Mechanism of ActionAspirin: Mechanism of Action

Membrane Phospholipids

Arachadonic Acid

Prostaglandin H2

COX-1

Thromboxane A2

Platelet AggregationVasoconstriction

Prostacyclin Platelet Aggregation

Vasodilation

Aspirin

Time delay recommended for regional Time delay recommended for regional anaesthesia in patients receiving antiplatelet anaesthesia in patients receiving antiplatelet

drugs*drugs*SEDARSEDAR ASRAASRA DGAIDGAI OGARIOGARI SFASFA

RR

ASAASA

NSAIDsNSAIDs

ClopidoClopidogrel or grel or TiclopidiTiclopidinene

GP GP IIb/IIIa IIb/IIIa inhibitoinhibitorsrs

FreeFree

FreeFree

Not Not recommendedrecommended

(Clopidogrel: (Clopidogrel: 7d)7d)

(Ticlopidine: (Ticlopidine: 10d)10d)


(abciximab – (abciximab – 24h 24h eptifibatide & eptifibatide & tirofiban – 8h)tirofiban – 8h)

FreeFree

FreeFree

ContraindicatContraindicateded




(Safety time (Safety time according to according to the drug)the drug)

Free/2days**Free/2days**

FreeFree





2 days2 days******Depending on the Depending on the drugdrug




ContraindicateContraindicatedd

(Safety time (Safety time according to according to the drug)the drug)

FreeFree

FreeFree

Not Not recorecommemmendednded

No No datadata

•In all cases it is specified that combination with other haemostasis-altering drugs In all cases it is specified that combination with other haemostasis-altering drugs entails a greater risk of developing epidural haemorrhage that should be evaluated entails a greater risk of developing epidural haemorrhage that should be evaluated individually, and the need for a normal platelet countindividually, and the need for a normal platelet count..

•** When ASA is given as a unique drug, neuraxial anaesthesia could be performed ** When ASA is given as a unique drug, neuraxial anaesthesia could be performed free and the recommended interval of at least 2 days will be established in cases of free and the recommended interval of at least 2 days will be established in cases of thromboprophylaxis with LMWH beginning in the preoperative stagethromboprophylaxis with LMWH beginning in the preoperative stage

•*** Interval of 2 days only in case of single-shot attraumatic technique; interval of 3 *** Interval of 2 days only in case of single-shot attraumatic technique; interval of 3 days recommended in case of other techniquesdays recommended in case of other techniques


Existing recommendations are similarExisting recommendations are similar

Small variations in safety periods and in the Small variations in safety periods and in the distinction between distinction between ‘contraindicated’‘contraindicated’ and and ‘not recommended’‘not recommended’. .

Reintroduction of antiaggregants Reintroduction of antiaggregants has been has been recommended in therecommended in the immediate immediate postoperative periodpostoperative period (ASA - between 6 and (ASA - between 6 and 24h after surgery, clopidogrel 75mg, 24h after surgery, clopidogrel 75mg, ticlopidine 250 mg immediately after the ticlopidine 250 mg immediately after the anaesthetic technique) anaesthetic technique)

Regional Anaesthesia in patients Regional Anaesthesia in patients receiving Oral Anticoagulants (OA)receiving Oral Anticoagulants (OA)

OA act by inhibiting the gamma OA act by inhibiting the gamma carboxylation of the vitamin K-dependent carboxylation of the vitamin K-dependent coagulation factors (II, VII, IX and X) and coagulation factors (II, VII, IX and X) and proteins C and S.proteins C and S.

Europe: acenocoumarolEurope: acenocoumarol – 3 days required – 3 days required for normalization of coagulationfor normalization of coagulation

US – WarfarinUS – Warfarin - 5 days required for - 5 days required for normalization of coagulationnormalization of coagulation

Warfarin

Synthesis of Non

Functional Coagulation

Factors

Antagonismof

Vitamin K

Vitamin K

VII

IX

X

II

Warfarin: Mechanism of ActionWarfarin: Mechanism of Action

Ansell J et al. Council on Clinical Cardiology. www.americanheart.org

Recommendations for regional anaesthesia in Recommendations for regional anaesthesia in patients receiving oral anticoagulants (OA) patients receiving oral anticoagulants (OA)

(acenocoumarol/warfarin)(acenocoumarol/warfarin)SEDARSEDAR

(acenocoum(acenocoumarol)arol)

ASRAASRA

(warfarin(warfarin))

DGAIDGAI

(acenocouma(acenocoumarol)rol)

OGARIOGARI

(acenocouma(acenocoumarol)rol)

BARABARA

(dependi(depending on ng on the the drug)drug)

SuspensionSuspension

MonitoringMonitoring

Puncture Puncture with/without with/without catheter catheter following OAfollowing OA

Removal of the Removal of the cathetercatheter

Initiation of OA Initiation of OA following following removal of the removal of the cathetercatheter

3-5 days 3-5 days beforebefore

Always INRAlways INR

INR ≤ 1.5INR ≤ 1.5

INR ≤ 1.5INR ≤ 1.5

ImmediateImmediate


Always Always INRINR

Normal Normal INRINR

INR < 1.5INR < 1.5

ImmediatImmediatee

--


INR < 1.4INR < 1.4

--

ImmediateImmediate



INR < 1.4INR < 1.4

--

ImmediateImmediate

--

Always Always INRINR

CI if CI if therapetherapeuticutic

INR < INR < 1.41.4

--


Existing recommendations are Existing recommendations are similar with no significant similar with no significant differences between them.differences between them.

Regional Anaesthesia in patients Regional Anaesthesia in patients anticoagulated with unfractionated anticoagulated with unfractionated

heparin (UH)heparin (UH)

UH act by promoting the inhibitory action of UH act by promoting the inhibitory action of antithrombin III (ATIII) on IIa, Xa, IXa, XIa and antithrombin III (ATIII) on IIa, Xa, IXa, XIa and XIIa factors and kallikrein.XIIa factors and kallikrein.

Elimination half-life is time and dose Elimination half-life is time and dose dependent, varying between 30 mins (25 dependent, varying between 30 mins (25 IU/kg-1) and 150min (400 IU/kg-1) according IU/kg-1) and 150min (400 IU/kg-1) according to route and dose givento route and dose given

Hirsh, J. et al. Chest 2001;119:64-94S

The heparin/AT-III complex inactivates the

Recommendations for regional anaesthesia in Recommendations for regional anaesthesia in patients receiving intravenous* unfractionated patients receiving intravenous* unfractionated

heparin (UH)heparin (UH)

SEDASEDARR

ASRAASRA DGAIDGAI OGARIOGARI BARABARA

Puncture with or without Puncture with or without catheter after UHcatheter after UH

UH following non-traumatic UH following non-traumatic puncture with or without puncture with or without cathetercatheter

Removal of the catheter Removal of the catheter following UHfollowing UH

UH following removal of the UH following removal of the cathetercatheter

UH following traumatic punctureUH following traumatic puncture

4h4h

1h1h

4h4h

1h1h

6h6h

--

1h1h

2-4h2-4h

--

No No greategreater r intervintervalal

4h4h

1h1h

4h4h

1h1h

12h12h

4h4h

1h1h

4h4h

1h1h

--

--

1h1h

--

1h1h

--

All the guidelines emphasize the need for a normal range of aPTT and/or ACT All the guidelines emphasize the need for a normal range of aPTT and/or ACT laboratory testslaboratory tests..SEDAR: Sociedad Espanola de Anestesiologia y Reanimacion; ASRA: American Society of Regional SEDAR: Sociedad Espanola de Anestesiologia y Reanimacion; ASRA: American Society of Regional Anaesthesia; DGAI: Deutsche Gesellschaft fur Anaesthesiologie und Intensivmedizin; OGARI: Anaesthesia; DGAI: Deutsche Gesellschaft fur Anaesthesiologie und Intensivmedizin; OGARI: Osterreichischen Gesellschaft fur Anasthesiologie und Intensivmedizin; BARA: Belgian Association Osterreichischen Gesellschaft fur Anasthesiologie und Intensivmedizin; BARA: Belgian Association for Regional Anaesthesia.for Regional Anaesthesia.

*If the UH is given s.c, the ASRA considers that there are no contraindications for a *If the UH is given s.c, the ASRA considers that there are no contraindications for a regional technique, and the DGAI considers that the same safety interval as with i.v. regional technique, and the DGAI considers that the same safety interval as with i.v. administration (puncture/removal of the catheter following UH s.c. following administration (puncture/removal of the catheter following UH s.c. following puncture/removal of the catheter = 1h) must be maintained.puncture/removal of the catheter = 1h) must be maintained.


Existing recommendations are similar with Existing recommendations are similar with no significant differences between them.no significant differences between them.

Differences in recommendations following Differences in recommendations following the i.v. administration of UH are minimal, the i.v. administration of UH are minimal, and only the fact that safety intervals and only the fact that safety intervals differ in the case of traumatic puncture is differ in the case of traumatic puncture is worthy of mention.worthy of mention.

Regional anaesthesia in patients receiving Regional anaesthesia in patients receiving FondaparinuxFondaparinux

New class of selective inhibitors of New class of selective inhibitors of coagulation factor Xa (reversible) without coagulation factor Xa (reversible) without affecting thrombin action or platelet affecting thrombin action or platelet aggregationaggregation

Synthetic pentasaccharideSynthetic pentasaccharide

Bioavailabilty of 100% when given s.c. Bioavailabilty of 100% when given s.c.

Plasma peak occurs at 2 hours and the Plasma peak occurs at 2 hours and the elimination half-life ranges from 17 – 21 elimination half-life ranges from 17 – 21 hourshours

Recommendations for regional Recommendations for regional anaesthesia in patients receiving anaesthesia in patients receiving

fondaparinuxfondaparinux

SEDASEDARR

ASRAASRA DGAIDGAI OGARIOGARI BARABARA

Administration following non-Administration following non-traumatic puncture with or traumatic puncture with or without catheterwithout catheter

Removal of the catheter Removal of the catheter following administrationfollowing administration

Administration following Administration following removal of the catheterremoval of the catheter

6 – 8h6 – 8h

36h36h

12h12h

6 – 8h 6 – 8h (cathet(catheter er contraicontraindicatndicated)ed)

--

--

6 – 8h6 – 8h

20 – 20 – 22h22h

2 – 4 h2 – 4 h

6 – 8h6 – 8h

36h*36h*

4h4h

6 – 6 – 12h12h

36h36h

12h12h

SEDAR: Sociedad Espanola de Anestesiologia y Reanimacion; ASRA: American SEDAR: Sociedad Espanola de Anestesiologia y Reanimacion; ASRA: American Society of Regional Anaesthesia; DGAI: Deutsche Gesellschaft fur Anaesthesiologie Society of Regional Anaesthesia; DGAI: Deutsche Gesellschaft fur Anaesthesiologie und Intensivmedizin; OGARI: Osterreichischen Gesellschaft fur Anasthesiologie und und Intensivmedizin; OGARI: Osterreichischen Gesellschaft fur Anasthesiologie und Intensivmedizin; BARA: Belgian Association for Regional Anaesthesia.Intensivmedizin; BARA: Belgian Association for Regional Anaesthesia.

* Need for anti-Xa activity in normal range* Need for anti-Xa activity in normal range


Relatively new drug in clinical Relatively new drug in clinical practice and perhaps that is why the practice and perhaps that is why the comparison of the recommendations comparison of the recommendations between different scientific societies between different scientific societies shows great heterogeity and shows great heterogeity and discrepancydiscrepancy

ConclusionConclusion Very few societies have produced guidelines or Very few societies have produced guidelines or

recommendations.recommendations.

Though significant differences in recommendations, Though significant differences in recommendations, aim is same – to reach the maximum safety in the aim is same – to reach the maximum safety in the performance of neuraxial regional techniques in performance of neuraxial regional techniques in patients receiving haemostasis-altering drugs.patients receiving haemostasis-altering drugs.

Practice of regional anaesthesia can be safely Practice of regional anaesthesia can be safely performed if the recommendations established by performed if the recommendations established by the different Scientific Societies of Anaesthesia are the different Scientific Societies of Anaesthesia are observed.observed.

To minimize disparity, it would be desirable and To minimize disparity, it would be desirable and feasible for an international working group to reach feasible for an international working group to reach consensus to establish universal recommendations.consensus to establish universal recommendations.

Take Home MessageTake Home Message

Thorough Thorough historyhistory to determine if to determine if bleeding problems are present.bleeding problems are present.

Do not attempt regional Do not attempt regional blockade( esp neuraxial blocks) if blockade( esp neuraxial blocks) if recommendedrecommended minimum haemostaticminimum haemostatic criteriacriteria are not fulfilled. are not fulfilled.

If the If the risk benefit ratiorisk benefit ratio weighs in weighs in favour of a regional block use the favour of a regional block use the following rule of thumb--following rule of thumb--

Puncture Puncture after last after last dosedose

Drug re-Drug re-startstart

Catheter Catheter removalremoval

Drug Drug restart restart after after catheter catheter removalremoval

LMWHLMWH 12 hrs12 hrs 6 hrs6 hrs 12 hrs12 hrs 6 hrs6 hrs

AspirinAspirin FreeFree 12 hrs12 hrs FreeFree FreeFree

Other Other anti-anti-platelet platelet drugsdrugs

AvoidAvoid ImmediatelImmediatelyy

Oral Oral AnticoagulaAnticoagulantsnts

3- 5 days3- 5 days Monitor Monitor INRINR

Monitor Monitor INRINR ImmediateImmediate

The The coagulopathic parturientcoagulopathic parturient presents a significant challenge with presents a significant challenge with the wide acceptability of labour the wide acceptability of labour epidurals and the proven benefit of epidurals and the proven benefit of regional techniques over general regional techniques over general anaesthesia.anaesthesia.

Kindly refer to the handout for a Kindly refer to the handout for a detailed discussion of the subject.detailed discussion of the subject.

THANK YOUTHANK YOU

Documents

Anticlotting Drugs and Regional Anaesthesia-1