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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