Regional Anesthesia in Patients on Anticoagulation Therapies—Evidence-Based Recommendations
- 89 Downloads
Purpose of Review
Anticoagulant use among patients is prevalent and increasing. It is important for anesthesiologists to be aware of patients on anticoagulants while performing regional anesthesia.
In recent years, the FDA has approved many new anticoagulants. With new drugs coming to the market, new side effect profiles should be considered when treating patients, especially when using regional anesthesia. Both ASRA and European agencies have laid out recommendations regarding anticoagulant use and neuraxial/regional techniques. Regarding newer anticoagulants, the guidelines for discontinuation prior to neuraxial injection are based on pharmacokinetics, including half-life duration for each drug.
While each clinical scenario requires an individualized approach, general guidelines can serve as a starting point to help with anesthetic planning and potentially improve patient safety in this evolving field.
KeywordsRegional anesthesia Anticoagulation therapies Neuraxial anesthesia Evidenced-based practice Anticoagulants
Compliance with Ethical Standards
Conflict of Interest
Andrew J. Brunk, Aaron J. Kaye, Jordan S Renschler, Brendon M. Hart, Prathima Anandi, Shilpa Patil, Elyse M. Cornett, and Charles J. Fox declare no conflict of interest. Alan D. Kaye discloses that he is on the Speakers Bureau for Depomed, Inc. and Merck.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Tryba M, Dietrich G. Epidural regional anesthesia and low molecular heparin: pro. AINS - Anästhesiologie Intensivmed Notfallmedizin Schmerztherapie, vol. 28. Stuttgart: © Georg Thieme Verlag; 1993. p. 179–84.Google Scholar
- 4.•• Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (Fourth Edition). Reg Anesth Pain Med. 2018;43:263–309. https://doi.org/10.1097/AAP.0000000000000763. These recently published guidelines are a good reference for health care providers. CrossRefGoogle Scholar
- 9.Li J, Halaszynski T. Neuraxial and peripheral nerve blocks in patients taking anticoagulant or thromboprophylactic drugs: challenges and solutions. Local Reg Anesth. 2015;4:21–32. https://doi.org/10.2147/LRA.S55306.
- 10.• Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (Fourth Edition). Reg Anesth Pain Med. 2018;43:263–309. These recently published guidelines are important for health care providers.Google Scholar
- 11.• Horlocker TT, Wedel DJ, Benzon H, Brown DL, Enneking FK, Heit JA, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003;28:172–97. This important manuscript discusses risks associated with patients on anticoagulants.PubMedGoogle Scholar
- 12.Narouze S, Benzon HT, Provenzano D, Buvanendran A, De Andres J, Deer T, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (Second Edition): 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. Reg Anesth Pain Med. 2018;43:225–262. https://doi.org/10.1097/AAP.0000000000000700.
- 13.Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM, et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010;27:999–1015 [cited 2016 Dec 14]. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003643-201012000-00001.CrossRefGoogle Scholar
- 14.Singelyn FJ, Verheyen CCPM, Piovella F, Van Aken HK, Rosencher N, EXPERT Study Investigators. The safety and efficacy of extended thromboprophylaxis with fondaparinux after major orthopedic surgery of the lower limb with or without a neuraxial or deep peripheral nerve catheter: the EXPERT study. Anesth Analg. 2007;105:1540–7.CrossRefGoogle Scholar
- 15.Michelson AD. Platelets: Elsevier; 3rd ed. Alan Michelson (ed): Academic Press. 2012 p. 1398Google Scholar
- 19.Stafford-Smith M. Impaired haemostasis and regional anaesthesia.Can J Anaesth. 1996;43:R129–41.Google Scholar