ANTIPLATELET DRUGS

• NSAIDs: neuraxial techniques probably OK
• by themselves, probably no significant added risk for spinal hematoma
• in combination with other anticoagulants (e.g. oral anticoagulants, standard heparin, and LMWH)
• data are lacking.
• however, the risk of bleeding complications may be increased.
• There is no perfect test to guide therapy. Bleeding test not proven to be predictive of spinal hematoma risk.
• At this time, there do not seem to be specific concerns as to the timing of single shot or catheter techniques in relationship to the dosing of NSAIDS, postoperative monitoring or the timing of neuraxial catheter removal.
• GP IIb/IIIa Receptor Antagonists: increased bleeding risk
• e.g., ticlopidine (Ticlid), clopidrogel (Plavix)
• No data available proving neuraxial techniques are safe
• More effective antiplatelet agents than NSAIDs
• Therefore, bleeding risk may be higher.
• Recommendations
• delay starting agents 12-24 hrs after uncomplicated spinal or epidural
• stop ticlopidine for 10-14 days, and clopidogrel for 7 days before performing neuraxial techniques

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STANDARD HEPARIN

• subcutaneous (mini-dose) prophylaxis
• no contradiction to use of neuraxial techniques
• risk of neuraxial bleeding may be...
• reduced by delay of the heparin injection until after the block
• increased in debilitated patients or after prolonged therapy.
• intraoperative anticoagulation
• avoid neuraxial techniques in patients with other coagulopathies.
• delay heparin administration for I hour after needle placement.
• remove catheter I hr before any subsequent heparin or 2-4 hrs after last heparin dose
• monitor patient postop for early detection of motor blockade; consider using minimal concentration of local anesthetics to enhance early detection of spinal hematoma.
• a bloody or difficult neuraxial needle placement may increase risk. However, there are no data to support mandatory cancellation of a case: clinical judgment is needed. If decide to proceed, full discussion with surgeon and careful postop monitoring are warranted.
• full anticoagulation of cardiac surgery
• sufficient data not available to determine if risk of neuraxial hematoma is increased.
• prolonged therapeutic anticoagulation
• increases risk of spinal hematoma, esp if combined with other anticoagulants or thrombolytics: neuraxial blocks should be avoided
• if systematic anticoagulation therapy is begun with epidural catheter in place, delay catheter removal for 2-4 hours following therapy discontinuation and evaluation of coagulation status.
• concurrent use of medications that affect other components of the clotting mechanisms (e.g., NSAIDS, LMWH and oral anticoagulants) may increase the risk of bleeding complications

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LOW MOLECULAR WEIGHT HEPARIN (LMWH)

• Monitoring of the anti-Xa level not recommended - not predictive of  risk of bleeding
• Coadministration with other anticoagulants (e.g., antiplatelet drugs, standard heparin, dextran) increases risk of bleeding.
• Presence of blood during needle and catheter placement
• does not necessitate postponement of surgery.
• however, should delay LMWH tx for 24 hours postoperatively.
• may signify increased risk of spinal hematoma - discus with surgeon.
• Patients on LMWH preoperatively:
• single-dose spinal anesthetic may be the safest neuraxial technique
• delay needle placement at least __ hrs after last LMWH dose:.
• 10-12 hrs if on low-dose (qd) schedule
• 24 hrs if on high-dose regimen  (e.g. enoxaparin I mg/kg bid)
• Patients to start LMWH thromboprophylaxis postoperatively
• may safely undergo single-dose and continuous catheter techniques.
• remove indwelling catheters before first dose.
• if epidural catheter left in overnight, remove the following day; delay first dose of LMWH till 2 hrs after catheter removal.
• Starting LMWH thromboprophylaxis with indwelling catheter
• extreme vigilance of neurologic status is warranted
• recommend opioid or dilute local anesthetic solution in order to allow frequent monitoring of neurologic function
• If epidural analgesia is anticipated to continue > 24 hours, consider...
• delaying LMWH administration (in selected cases), or
• using an alternate method of thromboprophylaxis (e.g. external pneumatic compression).
• These decisions should be made preoperatively to allow optimal management of both postoperative analgesia and thromboprophylaxis.
• Catheter Removal for any LMWH prophylaxis regimen:
• removal should be delayed for at least 10-12 hours after a dose of LMWH.
• true normalization of coag status possible if the evening dose of LMWH is held, and the catheter removed the following morning (24 hrs after last dose)
• delay subsequent dosing at least 2 hrs after catheter removal.

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FIBRINOLYTIC & THROMBOLYTIC DRUGS

• Concurrent with heparin
• probably at high risk of adverse neuraxial bleeding
• Fibrinolytics / thrombolytics alone
• pts should be cautioned against neuraxial anesthetics except in highly unusual circumstances.
• original guidelines for thrombolytics suggest avoidance of these drugs within 10 days of puncture of noncompressible vessels. Data are not available to clearly outline the length of time neuraxial puncture should be avoided after discontinuation of these drugs.
• Pts who have received neuraxial blocks at or near the time of fibrinolytic / thrombolytic therapy
• neurologic monitoring no less frequently than q 2 hrs
• if also ongoing epidural catheter infusion: limit infusion to drugs minimizing sensory and motor block
• Catheter removal
• no definitive recommendation
• measurement of fibrinogen may be helpful in making a decision about catheter removal or maintenance.

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