Perioperative Considerations and Management of Patients Receiving Anticoagulants

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Abstract

Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin (LMWH), fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring interventions. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease to use and more favorable pharmacodynamic profiles. Increasingly, anesthesiologists are being requested to anesthetize patients who are on some form of anticoagulants and hence it is important to have sound understanding of pharmacology, dosing, monitoring, and toxicity of anticoagulants. We searched the online databases including PubMed Central, Cochrane, and Google Scholar using anticoagulants, perioperative management, anesthetic considerations, and LMWH as keywords for the articles published between 1994 and 2015 while writing this review. In this article, we will review the different classes of anticoagulants and how to manage them in the perioperative settings.

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Most cited references 28

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Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology.

E Vandermeulen, Sibylle Kozek-Langenecker, Hugo Van Aken … (2010)

performing neuraxial anaesthesia in patients receiving antithrombotic drugs is controversial due to the increased risk of spinal epidural haematoma. Strict adherence to the recommended time intervals between the administration of anticoagulants, neuraxial blockade and the removal of catheters is thought to improve patient safety and reduce the risk of haematoma. Appropriate guidelines have been prepared by a number of national societies of anaesthesiologists, but they do not have universal acceptance. The introduction of new anticoagulants together with recent reports of stent thrombosis in patients with perioperative cessation of antiplatelet drugs have considerably broadened the issue and made revision necessary. To overcome deficiencies in content and applicability, the European Society of Anaesthesiology has taken the initiative to provide current and comprehensive guidelines for the continent as a whole. extensive review of the literature. in order to minimise bleeding complications during regional anaesthetic techniques, care should be taken to avoid traumatic puncture. If a bloody tap occurs when intraoperative anticoagulation is planned, postponing surgery should be considered. Alternatively, catheters can be placed the night before surgery. Regional anaesthesia in patients receiving full anticoagulation treatment continues to be contraindicated. Catheter manipulation and removal carry similar risks to insertion and the same criteria should apply. Appropriate neurological monitoring is essential during the postoperative recovery period and following catheter removal. The final decision to perform regional anaesthesia in patients receiving drugs that affect haemostasis has to be taken after careful assessment of individual risks and benefits.

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Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).

Terese T Horlocker, Denise Wedel, John Rowlingson … (2015)

The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize neurologic outcome is also consistently reported. In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result,the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology,hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.

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Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain.

Samer Narouze, Honorio T. Benzon, David Provenzano … (2024)

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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Journal

Journal ID (nlm-ta): Anesth Essays Res

Journal ID (iso-abbrev): Anesth Essays Res

Journal ID (publisher-id): AER

Title: Anesthesia, Essays and Researches

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 0259-1162

ISSN (Electronic): 2229-7685

Publication date (Print): Jan-Mar 2017

Volume: 11

Issue: 1

Pages: 10-16

Affiliations

[1]Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Author notes

Address for correspondence: Dr. R. Vasantha Kumari, Department of Anaesthesiology, Karnataka Institute of Medical Sciences, Hubli - 580 022, Karnataka, India. E-mail: drvasantha28@ 123456gmail.com

Article

Publisher ID: AER-11-10

DOI: 10.4103/0259-1162.179313

PMC ID: 5341681

PubMed ID: 28298749

SO-VID: 6b9f0792-44c6-45c7-b918-a4852cb66a6b

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Perioperative Considerations and Management of Patients Receiving Anticoagulants

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Most cited references 28

Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).

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