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Anticlotting drugs and regional anaesthetic and analgesic techniques: comparative update of the safety recommendations

Published online by Cambridge University Press:  01 May 2007

J. V. Llau ,
J. De Andrés ,
C. Gomar ,
A. Gómez-Luque ,
F. Hidalgo  and
L. M. Torres
J. V. Llau*
Affiliation:
Hospital Clinico Universitario, Department of Anaesthesiology, Critical Care and Pain Therapy, Valencia, Spain
J. De Andrés
Affiliation:
ConsorcioHospital General Universitario, Department of Anaesthesiology, Critical Care and Pain Therapy, Valencia, Spain
C. Gomar
Affiliation:
Hospital Clínic, Department of Anaesthesiology, Critical Care and Pain Therapy, Barcelona, Spain
A. Gómez-Luque
Affiliation:
Hospital Clínico Universitario, Department of Anaesthesiology, Critical Care and Pain Therapy, Málaga, Spain
F. Hidalgo
Affiliation:
Clínica Universitaria de Navarra, Department of Anaesthesiology, Critical Care and Pain Therapy, Pamplona, Spain
L. M. Torres
Affiliation:
Hospital Puerta del Mar, Department of Anaesthesiology, Critical Care and Pain Therapy, Cádiz, Spain
*
Correspondence to: Juan V. Llau, Department of Anaesthesiology, Critical Care and Pain Therapy, Hospital Clínico Universitario, Avda. Blasco Ibáñez, 17, 46010, Valencia, Spain. E-mail: juanvllau@terra.es; Tel: +34 963862653; Fax: +34 963862644
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Summary

The wide use of anticlotting drugs by patients scheduled for surgery is a challenge for the anaesthesiologist when considering a regional anaesthesia technique. This practice seems safe if there is an appropriate management based on safety intervals established according to the pharmacology of the drug and the regional technique. Some anaesthesiology societies have published recommendations for the safe practice of regional anaesthesia with the simultaneous use of anticoagulants (heparin, low molecular weight heparins, oral anticoagulants (OA), fondaparinux and others) and antiplatelet agents (aspirin, clopidogrel, ticlopidine, argatroban and others). One of the most recent guidelines has been published by the Spanish Society of Anaesthesia and Critical Care. This article reviews these recommendations and compares them with others published in the last years. The recommendations are similar, but some interesting differences can be observed and need to be considered. A European consensus in this setting would probably be necessary.

Keywords

CONDUCTION ANAESTHESIAGUIDELINESHEPARINDRUG INTERACTIONSBLOOD COAGULATIONVENOUS THROMBOSIS, prophylaxisPLATELET AGGREGATION INHIBITORS
Type
Review
Information
European Journal of Anaesthesiology , Volume 24 , Issue 5 , May 2007 , pp. 387 - 398
Copyright
Copyright © European Society of Anaesthesiology 2006

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References

1.Horlocker, TT, Wedel, DJ, Schoroder, SH, Elliot, BA, McGregor, DG, Wong, GY. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anest Analg 1995; 80: 303–309.Google Scholar
2.Horlocker, TT, Wedel, DJ, Benzon, H et al. . Regional anesthesia in the anticoagulated patient: Defining the risks. Reg Anesth Pain Med 2004; 29 (Suppl 1): 1–11.Google Scholar
3.Llau, JV, De Andrés, J, Gomar, C et al. . Drugs that alter hemostasis and regional anesthetic techniques: safety guidelines. Consensus conference (Spanish). Rev Esp Anestesiol Reanim 2001; 48: 270–278.Google Scholar
4.Gogarten, W, Van Aken, H, Büttner, J, Riess, H, Wulf, H, Buerkle, H. Rückenmarksnahe Regionalanästhesien und Thromboembolieprophylaxe / antithrombotische Medikation. Überarbeitete Leitlinien der Deustchen Gesellschaft für Anästhesiologie und Intensivmedizin. Anästh Intensivmed 2003; 44: 218–230.Google Scholar
5.Horlocker, TT, Wedel, DJ, Benzon, H 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: 172–197.Google ScholarPubMed
6.Llau Pitarch, JV, De Andrés Ibáñez, J, Gomar Sancho, C, Gómez Luque, A, Hidalgo Martínez, F, Torres Morera, LM. Guidelines of hemostasis inhibiting drugs and neuraxial anaesthesia (Spanish). Rev Esp Anestesiol Reanim 2005; 52: 413–420.Google Scholar
7.Kozek-Langenecker, SA, Fries, D, Gütl, M et al. . Lokoregionalanästhesien unter gerinnungshemmender Medikation. Anaesthesist 2005; 54: 476–484.Google Scholar
8.Vandermeulen, E, Singelyn, F, Vercauteren, M, Brichant, JF, Ickx, BE, Gautier, P. Belgian guidelines concerning central neural blockade in patients with drug induced alteration of coagulation: an update. Acta Anaesthesiol Belg 2005; 56: 139–146.Google ScholarPubMed
9.Samama, CM, Bastien, O, Forestier, F et al. , and the expert group. Antiplatelet agents in the perioperative period: expert recommendations of the French Society of Anesthesiology and Intensive Care (SFAR) 2001 – Summary statement. Can J Anesth 2002; 49: S26–S35.Google ScholarPubMed
10.Llau Pitarch, JV, De Andrés Ibáñez, J, Gomar Sancho, C, Gómez Luque, A, Hidalgo Martínez, F, Torres Morera, LM. Hemostasis-altering drugs and techniques for regional anaesthesia and analgesia: safety recommendations (Spanish). Rev Esp Anestesiol Reanim 2005; 52: 248–250.Google Scholar
11.Llau Pitarch, JV, De Andrés Ibáñez, J, Gomar Sancho, C, Gómez Luque, A, Hidalgo Martínez, F, Torres Morera, LM. Hemostasis-altering drugs and regional anaesthetic techniques: safety guidelines (Spanish). Rev Esp Anaestesiol Reanim 2004; 51: 137–142.Google Scholar
12.Llau Pitarch, JV, De Andrés Ibáñez, J, Gomar Sancho, C, Gómez Luque, A, Hidalgo Martínez, F, Torres Morera, LM. European Society for Regional Anaesthesia: Locoregional anaesthesia and drugs that affect hemostasis. Suggestions of the expert meeting in the ESRA Congress in Barcelona. Rev Esp Anestesiol Reanim 2002; 49: 468–473.Google ScholarPubMed
13.Geerts, WH, Heit, JA, Clagett, GP et al. . Prevention of venous thromboembolism. Chest 2001; 119 (Suppl): 132S–175S.CrossRefGoogle ScholarPubMed
14.Turpie, AG. State of the art – a journey through the world of antithrombotic therapy. Semin Thromb Hemost 2002; 28 (Suppl 3): 3–11.CrossRefGoogle ScholarPubMed
15.Horlocker, TT, Wedel, DJ. Neuraxial block and low-moleular-weight heparin: balancing perioperative analgesia and thromboprophylaxis. Reg Anesth Pain Med 1998; 23 (Suppl 2): 164–177.Google ScholarPubMed
16.Tryba, M. European practice guidelines: thromboembolism prophylaxis and regional anesthesia. Reg Anesth Pain Med 1998; 23 (Suppl 2): 178–182.Google ScholarPubMed
17.Lee, BB. Neuraxial complications after epidural and spinal anaesthesia. Acta Anaesthesiol Scand 2003; 47: 371–373.Google Scholar
18.Tyagi, A, Bhattacharya, A. Central neuraxial blocks and anticoagulation: a review of current trends. Eur J Anaesthesiol 2002; 19 (5): 317–329.Google Scholar
19.Franchini, M. The platelet function analyzer (PFA-100): an update on its clinical use. Clin Lab 2005; 51: 367–372.Google ScholarPubMed
20.Mandal, NJ. PFA-100 and regional anesthesia. Br J Anaesth 2004; 93: 468.Google Scholar
21.Favaloro, EJ. Clinical application of the PFA-100. Curr Opin Hematol 2002; 9: 407–415.Google Scholar
22.Tyagi, A, Bhattacharya, A. Central neuraxial blocks and anticoagulation: a review of current trends. Eur J Anaesthesiol 2002; 19: 317–329.CrossRefGoogle ScholarPubMed
23.Mentegazzi, F, Danelli, G, Ghisi, D, Tosi, M, Gennari, A, Fanelli, G. Locoregional anesthesia and coagulation. Minerva Anestesiol 2005; 71: 497–499.Google ScholarPubMed
24.Geerts, WH, Pineo, GF, Heit, JA et al. . Prevention of venous thromboembolism. Chest 2004; 126: 338S–400S.CrossRefGoogle ScholarPubMed
25.Weitz, JI. Low-molecular-weight heparins. N Engl J Med 1997; 337: 688–698.CrossRefGoogle ScholarPubMed
26.Hirsh, J, Warkentin, TE, Shaughenessy, SG et al. . Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest 2001; 119 (Suppl): 64S–94S.CrossRefGoogle ScholarPubMed
27.White, RH, Ginsberg, JS. Low-molecular-weight heparins: are they all the same? Br J Haematology 2003; 121: 12–20.CrossRefGoogle ScholarPubMed
28.Strebel, N, Prins, N, Agnelli, G, Buller, HR. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch Intern Med 2002; 162: 1451–1456.Google Scholar
29.Llau Pitarch, JV, Ferrandis Comes, R, García-Pérez, ML. Regional anaesthesia, thromboprophylaxis and their relationship with the spinal hematoma: Spanish experience (Spanish). Med Clin (Barc) 2003; 121: 414–417.CrossRefGoogle ScholarPubMed
30.Tufano, A, Cerbone, AM, Di Minno, G. The use of antithrombotic drugs in older people. Minerva Med 2002; 93: 13–26.Google Scholar
31.Patrono, C, Coller, B, FitzGerald, GA, Hirsh, J, Roth, G. Platelet active drugs: the relationships among dose, effectiveness, and side effects. Chest 2004; 126: 234S–264S.Google Scholar
32.CLASP (Collaborative Low-Dose Aspirin Study in Pregnancy): a randomized trial of low dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. Lancet 1994; 343: 619–629.CrossRefGoogle Scholar
33.Pulmonary Embolism Prevention (PEP) Trial Collaborative Group: prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: pulmonary embolism prevention (PEP). Lancet 2000; 355: 1295–1302.CrossRefGoogle Scholar
34.Kövesi, T, Royston, D. Is there a bleeding problem with platelet-active drugs? (Editorial). BJA 2002; 88: 159–162.Google Scholar
35.Burger, W, Chemnitus, JM, Kneissl, GD, Rücher, G. Low-dose aspirin for secondary cardiovascular prevention – cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation- review. J Inter Med 2005; 257: 399–414.CrossRefGoogle ScholarPubMed
36.Tam, NL, Pac-Soo, C, Pretorius, PM. Epidural haematoma after a combined spinal-epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br J Anaesth 2006; 96: 262–265.CrossRefGoogle Scholar
37.Litz, RJ, Gottschlich, B, Stehr, SN. Spinal epidural hematoma after spinal anesthesia in a patient treated with clopidogrel and enoxaparin. Anesthesiology 2004; 101: 1467–1470.CrossRefGoogle Scholar
38.Ansell, J, Hirsh, J, Poller, L, Bussey, H, Jacobson, A, Hylek, E. The pharmacology and management of the vitamin k antagonists. Chest 2004; 126: 204S–233S.CrossRefGoogle ScholarPubMed
39.Dunn, A, Turpie, AGG. Perioperative management of patients on oral anticoagulants: a systematic review. Arch Intern Med 2003; 163: 901–908.CrossRefGoogle ScholarPubMed
40.Hirsh, J, Raschke, R. Heparin and low molecular-weight heparin. Chest 2004; 126: 188S–203S.CrossRefGoogle ScholarPubMed
[41]Cantó, M. Regional anaesthesia in cardiac surgery. Future or reality? (Ed) (Spanish). Rev Esp Anestesiol Reanim 2003; 50: 319–325.Google Scholar
42.Weitz, JI, Hirsh, J, Samama, MM. New anticoagulant drugs. Chest 2004; 126: 265S–286S.CrossRefGoogle ScholarPubMed
43.Donat, F, Duret, JP, Santoni, A et al. . The pharmacokinetics of fondaparinux sodium in healthy volunteers. Clin Pharmacokinet 2002; 41 (Suppl 2): 1–9.Google Scholar
44.Bauer, KA, Hawkins, DW, Peters, PC et al. . Fondaparinux, a syntetic pentasaccharide: the first of a new class of antithrombotic agents – the selective factor Xa inhibitors. Cardiovasc Drug Rev 2002; 20: 37–52.Google Scholar
45.Keam, SJ, Goa, KL. Fondaparinux sodium. Drugs 2002; 62: 1673–1685.CrossRefGoogle ScholarPubMed
46.Westphal, M, Booke, M. Zum neuartigen Antithrombotikum Fondaparinux. Anästh Intensivmed 2003; 44: 324–325.Google Scholar
47. Singelyn FJ, Felicissimo P, Piovella F et al. Extended thromboprophylaxis with fondaparinux (Arixtra) after major orthopedic lower limb surgery: the EXPERT study. Oral Presentation, Lisbon EFORT, 2005, June 4–7 2005.Google Scholar