Anticoagulation 3rd Edition 2010
Regional Anesthesia and Pain Medicine:
January/February 2010 - Volume 35 - Issue 1 - pp 64-101
Asra Practice Advisory
Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)
Horlocker, Terese T. MD; Wedel, Denise J. MD; Rowlingson, John C. MD; Enneking, F. Kayser MD; Kopp, Sandra L. MD; Benzon, Honorio T. MD; Brown, David L. MD; Heit, John A. MD; Mulroy, Michael F. MD; Rosenquist, Richard W. MD; Tryba, Michael MD; Yuan, Chun-Su MD, PhD
Improvement in patient outcomes, including mortality, major morbidity, and patient-oriented outcomes, has been demonstrated with neuraxial techniques, particularly with epidural anesthesia and continued epidural analgesia.1-5 A major component of the decreased morbidity and mortality is due to the attenuation of the hypercoagulable response and the associated reduction in the frequency of thromboembolism after neuraxial blockade. Although this beneficial effect of neuraxial techniques continues to be recognized, the effect is insufficient as the sole method of thromboprophylaxis. Consequently, anticoagulant, antiplatelet, and thrombolytic medications have been increasingly used in the prevention and treatment of thromboembolism. For example, the initial recommendations in 1986 by the American College of Chest Physicians (ACCP) stated that patients undergoing hip arthroplasty receive dextran, adjusted-dose standard heparin (approximately 3500 U every 8 hrs), warfarin (started 48 hrs postoperatively to achieve a prothrombin time [PT] 1.25-1.5 times baseline), or dextran plus intermittent pneumatic compression (IPC).6 Two decades later, these patients are still identified as among the highest risk for thromboembolism and receive prophylaxis with low-molecular weight heparin (LMWH), fondaparinux (2.5 mg started 6-24 hrs postoperatively) or warfarin (started before or after operation with a mean target international normalized ratio [INR] of 2.5).7 However, adjusted-dose heparin, dextran, and venous foot pumps are no longer recommended as sole methods of thromboprophylaxis, although IPC is considered appropriate for patients at a high risk for bleeding. Importantly, the duration of thromboprophylaxis is continued after hospital discharge for a total of 10 to 35 days. Read more...