esa- antitrombotic therapy

Recommendations of the European Society of Anesthesiology

Gogarten, Wiebke; Vandermeulen, Erik; Van Aken, Hugo; Kozek, Sibylle; Llau, Juan V; Samama, Charles MEuropean Journal of Anaesthesiology. 27(12):999-1015, December 2010.

Miljenko MratinovićTomislav Čutura

Spinal epidural haematoma in patients on antithrombotic drugsFirst national recommendations on neuraxial

anaesthesia and antithrombotic drugs1997. German Society for Anaesthesiology and Intensive

Care1998. ASRA2000. Belgian anaesthesiologists

Regional anaesthesia and antithrombotic agents

Recommendations are based on case report and expert opinion ( mainly on knowledge of the pharmacokinetics of individual agent)

Mostly the time interval between cessation of medication and neuraxial blocade at 2x the elimination half-life of the drug.


The risk of haemorrhage ↓ spinal anaesthesia ↑epidural catether anaesthesia

½ of all cases of bleeding occur during the removal of an epidural catether


Tromboprophylaxis preoperatively vs. postoperatively (exeption neurosurgery)

A meta-analysis of preoperative vs. postoperative studies shows that LMWH given 12 h preoperatively does not reduce the risk of VTE compared to postoperative regime

German guidelines on thromboprophylaxis refer to preoperative administration only as an option, not as a requirement.


Because preoperative vs. postoperative thromboprophylaxis is not proven to be beneficial, in the presence of acetylsalicylic acid, VTE prophylaxis should be started postoperatively.

AHA recommends acetylsalicylic acid administration on a life-long basis and perioperative interruptions should be avoided in patients with DES/BMS.


Tromboprophylaxis preoperatively vs. postoperatively (exeption neurosurgery)

Antithrombotic drugs

Heparins - UFH, LMWHAnti-Xa agents - fondaparinux, idrabiotaparinux,

rivaroxaban, apixaban, danaparoid Direct trombin inhibitors - desirudin, lepirudin,

hirudin, argatrobanVitamin K antagonists - warfarin, fluindione,

acenocoumarol, phenprocoumon


Antithrombotic drugs

Platelet aggregation inhibitors - acetylsalicylic acid, thienopyridines, clopidogrel, selective serotonin reuptake inhibitors, glycoprotein IIb/IIIa inhibitors (abciximab, tirofibam, eptifibatide


HeparinsBinds to the enzyme inhibitor antithrombin III (AT)UFH – 1/2 elimination 60 min.

4-6h between iv. administration and puncture or catether manipulation or withdrawal ( aPTT normalised)

further administration delayed for 1h ( ACT maintained at 2x the baseline value)

LMWH – 1/2 elimination 4-7h12h between sc. administration and neuraxial blockade or

removal of an epidural cateter ( plasma anti-factor Xa activity)


Anti Xa agents inhibitors

Fondaparinux - alternative anticoagulant in HIT1/2 elimination 18h36h before catether removal, and 12h between the next dose

Idrabiotaparinux – 1/2 elimination 135h and up to 66 daysno data regarding neuraxial anesthesia

Rivaroxaban - 22-26h between the last dose and catether withdrawalnext dose may be given after 4-6h


Direct trombin inhibitors

Desirudin, lepirudin - 8-10h between the administration and neuraxial punction

Argatroban - administered iv. in treatment of HIT eliminated exclusively by liver 1/2 elimination 35-45 min ( normalisation of aPTT takes 2-4h)


Vitamin K antagonists

warfarin, fluindione, acenocoumarol, phenprocoumon

II, VII, IX, X coagulation factors normalisation of INR → INR<1,4 ( Vit.K, PCC,

FFP)


Platelet aggregation inhibitors

Acetylsalicylic acid irreversible inhibition of cyclo-oxygenase when given in isolation do not increase the risk of spinal epidural

haemathoma and are not a contraindication to neuraxial block

Thienopyridines - irreversible antagonosing ADP at the platelets purine receptors

Ticlopidine - neuraxial regional anesthesia should not be performed until 10 days elapsed between last ingestion and the procedure

Clopidrogel - 7 days after the last intake


Glycoprotein IIa/IIIb inhibitors - abciximab, tirofibam, eptifibatide the most potent form of platelet inhibition reduces thrombin generationare used only in ACS ( in combination with anticoagulants and

aspirin )cardiac surgery procedures are emergencies with continuing

antigoagulation → neuraxial blockade is contrainicated!


Platelet aggregation inhibitors

If a catheter has to be removed after administration of glycoprotein inhibitors, most guidelines recomend waiting at least 48h after abciximab, and 8-10 h after tirofiban or eptifibatide ( platelet count should be obtained to exclude thrombocytopenia )


HVALA!


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