Review Article| Volume 35, ISSUE 2, e21-e39, June 2017

Anticoagulation and Neuraxial/Peripheral Anesthesia


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        • Chery J.
        • Semaan E.
        • Darji S.
        • et al.
        Impact of regional versus general anesthesia on the clinical outcomes of patients undergoing major lower extremity amputation.
        Ann Vasc Surg. 2014; 28: 1149-1156
        • Hausman Jr., M.S.
        • Jewell E.S.
        • Engoren M.
        Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications?.
        Anesth Analg. 2015; 120: 1405-1412
        • Vadivelu N.
        • Gesquire M.
        • Mitra S.
        • et al.
        Safety of local anesthesia combined with monitored intravenous sedation for American Society of Anesthesiologists 3 and 4 patients undergoing lower limb-preservation procedures.
        J Foot Ankle Surg. 2010; 49: 152-154
        • Stevens R.D.
        • Van Gessel E.
        • Flory N.
        • et al.
        Lumbar plexus block reduces pain and blood loss associated with total hip arthroplasty.
        Anesthesiology. 2000; 93: 115-121
        • Long J.B.
        • Joselyn A.S.
        • Bhalla T.
        • et al.
        • PRAN Investigators
        The use of neuraxial catheters for postoperative analgesia in neonates: a multicenter safety analysis from the Pediatric Regional Anesthesia Network.
        Anesth Analg. 2016; 122: 1965-1970
        • Lou F.
        • Sun Z.
        • Huang N.
        • et al.
        Epidural combined with general anesthesia versus general anesthesia alone in patients undergoing free flap breast reconstruction.
        Plast Reconstr Surg. 2016; 137: 502e-509e
        • Capdevila X.
        • Dadure C.
        Perioperative management for one day hospital admission: regional anesthesia is better than general anesthesia.
        Acta Anaesthesiol Belg. 2004; 55: 33-36
        • Apfel C.C.
        • Korttila K.
        • Abdalla M.
        • et al.
        A factorial trial of six interventions for the prevention of postoperative nausea and vomiting.
        N Engl J Med. 2004; 350: 2441-2451
        • Day A.R.
        • Smith R.V.
        • Scott M.J.
        • et al.
        Randomized clinical trial investigating the stress response from two different methods of analgesia after laparoscopic colorectal surgery.
        Br J Surg. 2015; 102: 1473-1479
        • Tedore T.
        Regional anaesthesia and analgesia: relationship to cancer recurrence and survival.
        Br J Anaesth. 2015; 115: ii34-ii45
        • Vandermeulen E.P.
        • Van Aken H.
        • Vermylen J.
        Anticoagulants and spinal-epidural anesthesia.
        Anesth Analg. 1994; 79: 1165-1177
        • Horlocker T.T.
        • Wedel D.J.
        • Rowlingson J.C.
        • et al.
        Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).
        Reg Anesth Pain Med. 2010; 35: 64-101
        • Benzon H.T.
        • Wong H.Y.
        • Siddiqui T.
        • et al.
        Caution in performing epidural injections in patients on several antiplatelet drugs.
        Anesthesiology. 1999; 91: 1558-1559
      1. George M, Brenner CWS. Anticoagulant, antiplatelet, and fibrinolytic drugs. Accessed July 31, 2016.

      2. Horlocker TT. Neuraxial anesthesia and anticoagulation. Faust's anesthesiology review. 4th edition.

        • Gross L.
        • Aradi D.
        • Sibbing D.
        Platelet function testing in patients on antiplatelet medications.
        Semin Thromb Hemost. 2016; 42: 306-320
        • Glenn E.
        • Mehl J.
        • Rosinia F.A.
        • et al.
        Safe removal of an epidural catheter 72 hours after clopidogrel and aspirin administrations guided by platelet function analysis and thromboelastography.
        J Anaesthesiol Clin Pharmaco. 2013; 29: 99-101
        • Lippi G.
        • Montagnana M.
        • Danese E.
        • et al.
        Glycoprotein IIb/IIIa inhibitors: an update on the mechanism of action and use of functional testing methods to assess antiplatelet efficacy.
        Biomark Med. 2011; 5: 63-70
        • Frontera J.A.
        • Lewin 3rd, J.J.
        • Rabinstein A.A.
        • et al.
        Guideline for reversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine.
        Neurocit Care. 2016; 24: 6-46
      3. Jack Hirsh C, Raschke R. Heparin and low-molecularweight heparin The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest. 2004.

        • Makary A.Z.
        • Waterbury L.
        The activated partial thromboplastin time as a monitor of heparin therapy: a warning.
        Johns Hopkins Med J. 1977; 140: 311-315
        • Sandhu H.
        • Morley-Forster P.
        • Spadafora S.
        Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis.
        Reg Anesth Pain Med. 2000; 25: 72-75
        • King C.S.
        • Holley A.B.
        • Jackson J.L.
        • et al.
        Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: a metaanalysis.
        Chest. 2007; 131: 507-516
        • Svircevic V.
        • van Dijk D.
        • Nierich A.P.
        • et al.
        Meta-analysis of thoracic epidural anesthesia versus general anesthesia for cardiac surgery.
        Anesthesiology. 2011; 114: 271-282
        • Kakkar V.V.
        • Djazaeri B.
        • Fok J.
        • et al.
        Low-molecular-weight heparin and prevention of postoperative deep vein thrombosis.
        Br Med J (Clin Res Ed). 1982; 284: 375-379
        • Dooley C.
        • Kaur R.
        • Sobieraj D.M.
        Comparison of the efficacy and safety of low molecular weight heparins for venous thromboembolism prophylaxis in medically ill patients.
        Curr Med Res Opin. 2014; 30: 367-380
      4. Villa-Forte Gomes MP. FIRST CONSULT Principles of anticoagulation Clinical Key: FIRST CONSULT. 2012. Accessed May 05, 2016.

        • McCoy C.C.
        • Lawson J.H.
        • Shapiro M.L.
        Management of anticoagulation agents in trauma patients.
        Clin Lab Med. 2014; 34: 563-574
        • Bergqvist D.
        • Lindblad B.
        • Mätzsch T.
        Risk of combining low molecular weight heparin for thromboprophylaxis and epidural or spinal anesthesia.
        Semin Thromb Hemost. 1993; 19: 147-151
        • Niessner A.
        • Tamargo J.
        • Morais J.
        • et al.
        Reversal strategies for non-vitamin K antagonist oral anticoagulants: a critical appraisal of available evidence and recommendations for clinical management-a joint position paper of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and European Society of Cardiology Working Group on Thrombosis.
        Eur Heart J. 2015;
        • Benzon H.T.
        • Benzon H.A.
        • Kirby-Nolan M.
        • et al.
        Factor VII levels and international normalized ratios in the early phase of Warfarin therapy.
        Anesthesiology. 2010; 112: 298-304
        • Gulur P.
        • Tsui B.
        • Pathak R.
        • et al.
        Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters.
        British Journal of Anaesthesia. 2015; 114: 808-811
        • Wysowski D.K.
        • Nourjah P.
        • Swartz L.
        Bleeding complications with warfarin use: a prevalent adverse effect resulting in regulatory action.
        Arch Intern Med. 2007; 167: 1414-1419
        • Raji M.A.
        • Lowery M.
        • Lin Y.L.
        • et al.
        National utilization patterns of warfarin use in older patients with atrial fibrillation: a population-based study of Medicare Part D beneficiaries.
        Ann Pharmacother. 2013; 47: 35-42
        • Barnes G.D.
        • Lucas E.
        • Alexander G.C.
        • et al.
        National trends in ambulatory oral anticoagulant use.
        Am J Med. 2015; 128: 1300-1305
        • Healey J.S.
        • Eikelboom J.
        • Douketis J.
        • et al.
        • RE-LY Investigators
        Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial.
        Circulation. 2012; 126: 343-348
        • Bonar R.
        • Favaloro E.J.
        • Mohammed S.
        • et al.
        The effect of the direct factor Xa inhibitors apixaban and rivaroxaban on haemostasis tests: a comprehensive assessment using in vitro and ex vivo samples.
        Pathology. 2016; 48: 60-71
        • van Ryn J.
        • Stangier J.
        • Haertter S.
        • et al.
        Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity.
        Thromb Haemost. 2010; 103: 1116-1127
        • Stangier J.
        • Rathgen K.
        • Stähle H.
        • et al.
        The pharmacokinetics, pharmacodynamics and tolerability of dabigatran etexilate, a new oral direct thrombin inhibitor, in healthy male subjects.
        Br J Clin Pharmacol. 2007; 64: 292-303
        • Zahir H.
        • Brown K.S.
        • Vandell A.G.
        • et al.
        Edoxaban effects on bleeding following punch biopsy and reversal by a 4-factor prothrombin complex concentrate.
        Circulation. 2015; 131: 82-90
        • Di Nisio M.
        • Middeldorp S.
        • Büller H.R.
        Direct thrombin inhibitors.
        N Engl J Med. 2005; 353: 1028-1040
        • Gogarten W.
        • Vandermeulen E.
        • Van Aken H.
        • et al.
        • European Society of Anaesthesiology
        Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology.
        Eur J Anaesthesiol. 2010; 27: 999-1015
        • Ginsberg J.S.
        • Davidson B.L.
        • Comp P.C.
        • et al.
        • RE-MOBILIZE Writing Committee
        Oral thrombin inhibitor dabigatran etexilate vs North American enoxaparin regimen for prevention of venous Thromboembolism.
        J Arthroplasty. 2009; 24: 1-9
        • Fuji T.
        • Fuijita S.
        • Ujihira T.
        • et al.
        Dabigatran etexilate prevents venous thromboembolism after total knee arthroplasty in Japanese patients with safety profile comparable to placebo.
        J Arthroplasty. 2010; 9: 1267-1274
        • Levy J.H.
        • Key N.S.
        • Azran M.S.
        Novel oral anticoagulants: implications in the perioperative setting.
        Anesthesiology. 2010; 113: 726-745
        • Benzon H.T.
        • Avram M.J.
        • Green D.
        • et al.
        New oral anticoagulants and regional anaesthesia.
        Br J Anaesth. 2013; 111: 96-113
        • Rosencher N.
        • Bonnet M.P.
        • Sessler D.I.
        Selected new antithrombotic agents and neuraxial anaesthesia for major orthopaedic surgery: management strategies.
        Anaesthesia. 2007; 11: 1154-1160
        • Sié P.
        • Samama C.M.
        • Godier A.
        • et al.
        • Working Group on Perioperative Haemostasis
        • French Study Group on Thrombosis and Haemostasis
        Surgery and invasive procedures in patients on long-term treatment with direct oral anticoagulants: thrombin or factor-Xa inhibitors. Recommendations of the Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis.
        Arch Cardiovasc Dis. 2011; 104: 669-676
        • Tetri S.
        • Hakala J.
        • Juvela S.
        • et al.
        Safety of low-dose subcutaneous enoxaparin for the prevention of venous thromboembolism after primary intracerebral haemorrhage.
        Thromb Res. 2008; 123: 206-212
        • Chai-Adisaksopha C.
        • Hillis C.
        • Lim W.
        • et al.
        Hemodialysis for the treatment of dabigatran-associated bleeding: a case report and systematic review.
        J Thromb Haemost. 2015; 10: 1790-1798
        • Hu T.Y.
        • Vaidya V.R.
        • Asirvatham S.J.
        Reversing anticoagulant effects of novel oral anticoagulants: role of ciraparantag, andexanet alfa, and idarucizumab.
        Vasc Health Risk Manag. 2016; 12: 35-44
        • Samama M.
        The mechanism of action of rivaroxaban–an oral, direct Factor Xa inhibitor–compared with other anticoagulants.
        Thromb Res. 2011; 127: 497-504
        • Singelyn F.J.
        • Verheyen C.C.
        • Piovella F.
        • et al.
        • EXPERT Study Investigators
        The safety and efficacy of extended thromboprophylaxis with fondaparinux after major orthopedic surgery of the lower limb with or without a neuraxial or deep peripheral nerve catheter: the EXPERT study.
        Anesth Analg. 2007; 105: 1540-1547
        • Siegal D.M.
        • Curnutte J.T.
        • Connolly S.J.
        • et al.
        Andexanet alfa for the reversal of factor Xa inhibitor activity.
        N Engl J Med. 2015; 373: 2413-2424
        • Ansell J.E.
        Reversing the effect of oral anticoagulant drugs: established and newer options.
        Am J Cardiovasc Drugs. 2016; 16: 163-170
        • Kaye A.D.
        • Clarke R.C.
        • Sabar R.
        • et al.
        Herbal medicines: current trends in anesthesiology practice–a hospital survey.
        J Clin Anesth. 2000; 12: 468-471
      5. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Interim update: Anticoagulation. 3rd edition. 2016.