Evolving standards for the prevention of perioperative venous thromboembolism VTE and the introduction of increasingly potent antithrombotic medications have resulted in concerns regarding the heightened risk of neuraxial bleeding. Furthermore, societies and organizations seeking to address these concerns through guidelines in perioperative management have issued conflicting recommendations. Earlier guidelines did not specify a time interval between SC administration of UFH and neuraxial blockade. These recommendations are based on the pharmacology of SC U dose of UFH, which results in a significant anticoagulant effect that persists 4 to 6 hours after administration.
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In , that issue came to fruition with the publication of consensus guidelines clarifying preprocedural and postprocedural management of nine classes of medications.
A framework for risk assessment and stratification was also created on the basis of procedural risks, relevant anatomy, and potential for severe neurological injury. Although the framework for evaluating periprocedural risk remained essentially unchanged, in April notable updates were released in several areas, including risk reclassification of some pain procedures, new recommendations for newer medications, recommendations for dietary supplements, and adjusted recommendations for heparin and fondaparinux.
The update includes additional evidence supporting diligence in the management of novel oral anticoagulants NOACs before and after neuraxial interventions, recommendations for considering coagulation studies in patients with renal or hepatic disease, and recommendations for routine use of physical examination findings for signs or symptoms of coagulopathy. As expected, the committee included dorsal root ganglion stimulation and percutaneous decompression laminectomy as new entrants to the high-risk procedure category.
Other changes include reducing peripheral nerve stimulation PNS , PNS implantation, and device pocket revision to the low-risk category as well. The changes are worth noting because nearly all summary recommendations in the publication require assessing procedural risk to establish appropriate medication management.
Authors included new recommendations and considerations for spinal cord stimulation SCS therapy, which are aligned with those from the International Neuromodulation Society. Similar to recommendations for other intermediate and high-risk procedures, the committee recommends stopping clopidogrel seven days prior to SCS procedures with rare consideration of a five-day window coupled with platelet function testing to confirm recovery of function.
Noteworthy changes were made to recommendations surrounding intravenous IV heparin, subcutaneous heparin, and fondaparinux. The previous recommendation for a minimum window of 4 hours between cessation of IV heparin and performance of any interventional procedure was increased to 6 hours.
Conversely, the waiting period following subcutaneous heparin was decreased from 8—10 hours to a current recommendation of 6 hours. Although the recommendations for holding and restarting NOACs remain unchanged, a new entrant into the category, edoxaban, was included. In general, recommendations for that class of medication include stopping it 3 days prior to a procedure, which represents a five half-life interval a recurring theme across several drug classes.
Three cases of serious, adverse bleeding in patients taking NOACs were reported, one of which was associated with removal of an epidural catheter. As a compliment to the previous recommendations on supplements, new recommendations discussed vitamin E, fish oil, and pentosan polysulfate a medication used in the treatment of interstitial cystitis. Interventionalists must remain aware of potentiating antiplatelet effects in patients taking supplements and direct antiplatelet agents simultaneously.
Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications second edition. Reg Anesth Pain Med. Used with permission. If a loading dose of clopidogrel is given, then the interval should be 24 hours.
As previously noted, considerable changes have been made to recommendations surrounding the management of antiplatelet and anticoagulant medications in patients receiving interventional spine and pain procedures. See Table 1 for a summary from the publication. Tags: guidelines, Anticoagulation guidelines, chronic pain. Reg Anesthes Pain Med. American Society of Regional Anesthesia and Pain Medicine Advancing the science and practice of regional anesthesiology and pain medicine to improve patient outcomes through research, education, and advocacy 3 Penn Center West, Suite Pittsburgh , PA About Calendar Patient information Corporate partners Donate.
Phosphodiesterase inhibitors. Shared assessment and risk stratification a. No, shared assessment and risk stratification a. Enoxaprin prophylactic. Enoxaprin therapeutic.
Fibrinolytic agents. P2Y12 inhibitors. No, shared assessment and risk stratification. Shared assessment and risk stratification. Antidepressants and SRIs. See text and Table 7.
Articles: Anticoagulation guidelines
Recent ASRA guidelines have attempted to align regional and pain guidelines, but this is not always possible. Why are there separate regional and pain guidelines? Pain procedures are more often treating elderly patients, patients with spinal stenosis, and scarring postlaminectomy patients. All patients had normal coagulation studies and followed ASRA guidelines.
The Daily Dose • Sunday, May 19
Advisories & guidelines
Updates to the ASRA Guidelines for Interventional Pain Procedures