Polypharmacy: Neuraxial Anesthesia and Anticoagulation

 

Indication for anticoagulation therapy
Risk stratum for thrombotic events
Mechanical heart valves
Atrial fibrillation
Venous thromboembolism
High risk
>10% annual risk for thromboembolism
Any mitral valve prosthesis
Any caged-ball or tilting disc aortic valve prosthesis
Recent (within 6 months) stroke or TIA
CHADS2 score of 5 of 6
Recent (within 3 months) stroke or TIA
Recent (within 3 months) VTE
Severe thrombophilia
Moderate risk
5–10% annual risk for thromboembolism
Bileaflet aortic valve prosthesis and ≥1 of the following risk factors: atrial fibrillation, prior stroke or TIA, hypertension, diabetes, CHF, age > 75 years
Rheumatic valvular heart disease
CHADS2 score of 3 or 4
VTE within the past 3–12 months
Recurrent VTE
Active cancer (treated within 6 months or palliative)
Nonsevere thrombophilia
Low risk
<5% annual risk for thromboembolism
Bileaflet aortic valve prosthesis without atrial fibrillation and no other risk factors for stroke
CHADS2 score of 0–2
VTE > 12 months previous and no other risk factors
CHF congestive heart failure, TIA transient ischemic attack, VTE venous thromboembolism
The CHADS2 score is calculated by the cumulative score of CHF (1 point), hypertension (1 point), age > 75 years (1 point), diabetes mellitus (1 point), and previous stroke or TIA (2 points)
Severe thrombophilias include deficiencies in protein C, protein S, antithrombin, antiphospholipid antibodies, or multiple abnormalities
Nonsevere thrombophilias include heterozygosity for factor V Leiden or prothrombin G20210A

33.6 Bleeding Risk Assessment

The assessment of bleeding risk requires assessment of patient- and procedure-specific characteristics. The extensive venous plexus of the epidural space is vulnerable to trauma from needle puncture, advancement of spinal cord stimulator leads, or epidural and intrathecal catheters. The fragility and caliber of these vessels increase with age and various physiologic or pathologic states. The anatomic narrowing of the spinal canal from a myriad of conditions may lower the threshold for neurologic compression and injury with spinal bleeding. Table 33.2, adapted from the ASRA 2015 guidelines for pain procedures, provides a risk assessment based on type of pain procedure.
Table 33.2
Pain procedure classification according to the potential risk for serious bleed [1]
High-risk procedures
Intermediate-risk proceduresa
Low-risk proceduresa
Spinal cord stimulation trial and implant
Intrathecal catheter and pump implant
Vertebral augmentation
Epiduroscopy and epidural decompression
Interlaminar ESIs (C, T, L, S)
Transforaminal ESIs (C,T, L, S)
Facet MBNB and RFA (C, T, L)
Paravertebral block (C, T, L)
Intradiscal procedures (C, T, L)
Sympathetic blocks (stellate, thoracic, splanchnic, celiac, lumbar, hypogastric)
Peripheral nerve stimulation trial and implant
Pocket revision and IPG/ITP replacement
Peripheral nerve blocks
Peripheral joints and musculoskeletal injections
Trigger point injections including piriformis injections
Sacroiliac joint injections and sacral lateral branch blocks
C cervical, L lumbar, MBNB medial branch nerve block, RFA radiofrequency ablation, S sacral, T thoracic, IPG internal pulse generator, ITP intrathecal pump
aPatients with high risk for bleeding undergoing low- or intermediate-risk procedures should be treated as intermediate or high risk, respectively. Patients with high risk for bleeding may include old age, history of bleeding tendency, concurrent uses of other anticoagulants/antiplatelets, liver cirrhosis or advanced liver disease, and advanced renal disease

33.7 Discontinuing Anticoagulation or Antiplatelet Treatment

Concurrent use of coagulation-altering medications may increase the risk of bleeding without altering coagulation studies. Catheters are placed and removed at the nadir of anticoagulant activity. Additional anticoagulants should not be given immediately after catheter removal. Before initiating neuraxial anesthesia , the patient’s medication list should identify the presence of anticoagulant or antiplatelet therapy. Common anticoagulants encountered in the surgical setting include antiplatelet medications, oral anticoagulants, unfractionated heparin, low molecular weight heparin, serotonin reuptake inhibitors, and herbal preparations.

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Feb 26, 2018 | Posted by in Uncategorized | Comments Off on Polypharmacy: Neuraxial Anesthesia and Anticoagulation

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