Antiplatelet and Anticoagulant management for Regional Anesthesia Deborah Richman MBCHB, FFA(SA) Director of Pre-Operative Services Department of Anesthesia Stony Brook MedicineStony Brook, NY SPAQI Immediate Past-President deborah.richman@stonybrookmedicine.edu The 13 th Annual Perioperative Medicine Summit Fort Lauderdale, Florida
Disclosures No financial disclosures SPAQI Immediate Past President #Periop2018 The 13 th Annual Perioperative Medicine Summit Fort Lauderdale, Florida
Learning Objectives After attending this session the learner will be able to: List the types and advantages of regional blocks Describe the risks of blocks Provide medication management instructions to patients on antiplatelet agents and anticoagulants, who are planning on a regional anesthesia technique for their procedure
Analgesia Intraop: Opiates IV neuraxial NSAIDs Acetaminophen Local Regional blocks Post op: IV or PO opiates and block catheters
Complications of analgesics Opiates Allergies Toxicity Side effects Histamine release PONV Respiratory depression Confusion Constipation Weakness/dizziness falls Tolerance/Addiction/Abuse Regional / local Allergies Toxicity Local effects Hematoma Infection Nerve injury
Regional anesthesia Abdominal Thoracic nerve blocks femoral/sciatic/adductor canal/ Field block brachial plexus/ nerve blocks/ Bier s block Lower extremity epidural/ intercostal/paravertebral Upper extremity spinal/ epidural/tap block ankle block/penile block Ophthalmology retrobulbar/peribulbar/subtenon/topical Risk of hematoma #Periop2018 Non compressible spaces Closed space spinal column
Neuraxial anesthesia / analgesia #Periop2018
Regional anesthesia any time you stick a needle anywhere, you run the risk of introducing infection, causing bleeding or damaging a nerve.
Spinal/epidural complications 1. Drug allergy or toxicity 2. Anatomic: Difficulty placing them Failed block 3. Bleeding Skin Sub-q Epidural hematoma 4. Back pain 5. Infection epidural abscess 6. Nerve damage 7. Spinal tap or persistent CSF leak post dural puncture headache(pdph) 8. High spinal 9. Hypotension Reviewing contraindications and avoiding block may be appropriate
Rare True incidence not known US: 3.7 million epidurals 1998-2010 OB epidurals: 0.6 per 100,000 Non-OB: 18.5 per 100,000 (1: 5450) Vascular surgery Teaching hospital High comorbidity score Rosero EB Acta Anesth Scand. Jul 2016. Vol 60,:6 pp 810 820 Sweden 1.26 million spinals and 450K epidurals 1990-1999 Spinal hematoma(1:158 000) < Epidural (1: 18 000) Obstetrics < other patients Females TKR / hip fracture 11/33 assoc with coagulopathy/thromboprophylaxis Moen V. Anesthesiology. 2004;101(4):950. Frequency is increasing and may be as high as 1 in 3000 in some patient populations. Risk factors Increasing age, Anatomical abnormalities of spine Underlying coagulopathy Procedural difficulty Indwelling neuraxial catheter with anticoagulation therapy Prompt diagnosis and management needed to prevent permanent neurological sequelae. #Periop2018 Neuraxial hematoma after anesthesia
Avoiding epidural hematoma 1. Careful patient selection 2. Meticulous technique 3. Appropriate medication management
Case 1 57 yr. old male for TKR under spinal anesthesia and femoral nerve block for analgesia Advantages Less DVT Less blood loss Less transfusion Better bone cement interface Better ROM of knee at 1 week and 30 days MI 14 months ago with PCI and DES Meds include DAPT ASA 81mg and Clopidogrel 75mg Cardiol. cleared patient; to hold both drugs for 5 days
ARS question Case 1 For the planned procedure and anesthesia you should recommend that he: A. Stays on DAPT perioperatively B. He should stop the ASA for 7 days and continue the clopidogrel C. He should stop the clopidogrel for 5 days and continue the ASA D. He should stop the clopidogrel for 7 days and continue the ASA E. You agree with his cardiologist - he should stop both clopidogrel and ASA for 5 days
The magnitude of incremental bleeding risk in patients treated with antiplatelet therapy who undergo surgery is uncertain (157,158). If P2Y12 inhibitor therapy needs to be held in patients being treated with DAPT after stent implantation, continuation of aspirin therapy if possible is recommended #Periop2018 Levine, GN, et al. http://circ.ahajournals.org/content/early/2016/03/28/cir.0000000000000404
Patient selection Benefit of regional vs. risk of holding anticoagulant/ antiplatelet therapy #Periop2018
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery Choice of Anesthetic Technique and Agent Fleisher LA, et al.2014 ACC/AHA Perioperative Guideline http://circ.ahajournals.org/content/early/2014/07/31/cir.0000000000000106
Neuraxial vs. General Anesthesia 1. Lower-limb revascularization 1 No difference in MI rate 2. Abdominal aortic surgery 2 No difference in MI or ischemia rate 1. Barbosa FT etal. Cochrane Database Syst Rev. 2013;7:CD007083. 2. Norris EJ etal. Anesthesiology. 2001;95:1054-67. Conclusion regional not cardio-protective No benefit
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery Perioperative Pain Management: Recommendations Class IIa 1. Neuraxial anesthesia for postoperative pain relief can be effective in patients undergoing abdominal aortic surgery to decrease the incidence of perioperative MI (348). (Level of Evidence:B) Class IIb 1. Perioperative epidural analgesia may be considered to decrease the incidence of preoperative cardiac events in patients with a hip fracture (349). (Level of Evidence: B) RCT: 64 patients - MI/HF/ischemia/AF Fleisher LA, et al.2014 ACC/AHA Perioperative Guideline http://circ.ahajournals.org/content/early/2014/07/31/cir.0000000000000106 349. Matot I, etal Anesthesiology. 2003;98:156-63. #Periop2018
Which is better? GA or neuraxial? Very few places where one is definitively better Regional blocks Longer to place Longer to discharge Deep vein thrombosis (DVT) reduced Less relevant in age of universal prophylaxis Blood loss reduced in total joint replacements Use of tranexamic acid makes this less relevant?cancer recurrence Opioid avoidance Direct effect on tumor cells Reduction of stress response Sekandarzad, MW. A&A May 2017. Vol 124(5), p 1697 1708
Does regional anaesthesia really improve outcome? Specific endpoints assessed Inflammation Cancer Stress Less opioids Platelet function GI function Mixed results. it remains unclear whether regional anaesthesia reduces mortality. However, regional anaesthesia offers superior analgesia over opioidbased analgesia, and a significant reduction in postoperative pain is still a worthwhile outcome. S. C. Kettner, etal. BJA 2011, vol107, Issue suppl i90-i95
Non-cardiac complications and choice of anesthesia Evidence is mixed and conflicting: Neuraxial better? GI/ileus - ERAS DVT 1 month mortality Post op confusion? Clinical significance Cost? Continuous analgesia No difference? PONV PE LOS Pneumonia #Periop2018
Avoiding epidural hematoma 1. Careful patient selection 2. Meticulous technique 3. Appropriate medication management Placement of block/catheter Removal of catheter Restarting medication
Medication management Simplify when possible to improve patient compliance
Supplements and Herbal agents Effect is minimal unless combined with other agents Surgeon usually wants these held Vit E Fish Oils Ginger Ginkgo Horlocker, TT. Regional Anesthesia and Pain Medicine: Jan-Feb 2010 Vol 35 - Iss 1 - p 64-101 Garlic Hold for 7 days Ginkgo and Ginger shorter t1/2 #Periop2018
1000 procedures with neuraxial Majority: ASA and NSAIDs N=25 Heparin No major bleeds/ neuro sequelae Conclusion: ASA and NSAIDs safe in the arthritic population who depend on drugs for mobility #Periop2018
Neuroaxial anesthesia and bleeding risk ASRA guidelines 1 : Supplements Herbals Aspirin NSAIDS Clopidogrel 7 days Prasugrel 7-10 days Ticagrelor 5-7 days Ticlopidine 14 days Coumadin normal INR Practically: Hold 4-5 doses depending on INR Check INR morning of surgery 1. Horlocker, TT. Regional Anesthesia and Pain Medicine: Jan-Feb 2010 Vol 35 - Iss 1 - p 64-101 https://www.asra.com/advisoryguidelines/article/1/anticoagulation-3rd-edition
57 yr. old male for TKR under spinal anesthesia and femoral nerve block for analgesia For the planned procedure and anesthesia you should recommend that he: A. Stays on DAPT perioperatively B. He should stop the ASA for 7 days and continue the clopidogrel C. He should stop the clopidogrel for 5 days and continue the ASA D. He should stop the clopidogrel for 7 days and continue the ASA E. You agree with his cardiologist - he should stop both clopidogrel and ASA for 5 days
Neuroaxial anesthesia and bleeding risk ASRA guidelines 1 : Heparin normal PTT 6 hours after IV. May do block if < 10 000 SC daily dose Delay dose till > 1 hr. after block placed LMWH - block Prophylactic dose 10-12 hours after last dose Therapeutic dose 24 hours after Fondaparinux no evidence: block not recommended Glycoprotein IIb/IIIa Abciximab 48 hours Tirofiban/eptifibatide 4-8 hours NOACs: next slide 1. Horlocker, TT. Regional Anesthesia and Pain Medicine: Jan-Feb 2010 Vol 35 - Iss 1 - p 64-101 https://www.asra.com/advisoryguidelines/article/1/anticoagulation-3rd-edition
Horlocker, TT. Regional Anesthesia and Pain Medicine: Jan-Feb 2010 Vol 35 - Iss 1 - p 64-101 https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition
Memorizing this for your practice ld o H d l al s g ru 7 r fo s y a d Please NO!! There is help #Periop2018
ASRA app $ / User friendly
Summary Consider: Risk of hematoma vs. advantage of block Risk of stopping ac/antiplt agent vs. advantage of block Refer to ASRA guidelines Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) https://www.asra.com/advisory-guidelines/article/1/anticoagulation-3rd-edition Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications: https://journals.lww.com/rapm/fulltext/2015/05000/interventional_spine_and_pain_procedur es_in.2.aspx Multidisciplinary consultation for best individualized management plan
Selected References Horlocker, TT. ASRA guidelines. Regional Anesthesia and Pain Medicine: Jan-Feb 2010 Vol 35 - Iss 1 - p 64-101 Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60:810. S. C. Kettner, H. Willschke, P. Marhofer; Does regional anaesthesia really improve outcome?, BJA: British Journal of Anaesthesia, Volume 107, Issue suppl_1, 1 December 2011, Pages i90 i95,
Thank you Deborah Richman MBCHB, FFA(SA) Stony BrookMedicine Stony Brook, NY SPAQI Immediate Past President deborah.richman@stonybrookmedicine.edu #Periop2018
Symptoms of spinal hematoma Severe back pain (38%) sensory (14%) motor deficit (46%) Urinary retention (6%) Not all of these symptoms have to be present at the same time. Paraplegia develop 12-18 hours #Periop2018 Vandermeulen EP. A&A 1994;79:1165-77