Case Reports in Anesthesia

Blog with interesting cases and/or problems related to anesthesia with discussion based on best
evidence in the literature.

New ASRA Guidelines

Recent ASRA published new guidelines on dealing with neuraxial catheters and injections in
patients who have or will undergo therapy or prophylactic treatment for
venousthromboembolism. I have provided a very general and quick review of some of the more
important portions. The full document is well done and referenced and so I've provided a link
for download.
ASRA quick review:
Thrombolytics

no recommendations regarding timing are provided. In general it is recommended to

avoid neuraxial or peripheral nerve blocks in patients who have or might received
thrombolytic therapy (i.e. streptokinase)

It should be noted that fibrinogen and plasminogen levels are maximally supressed at 5
hours post administration. These factors are still significantly suppressed at 27 hrs
post administration.

UFH
(Unfractionated
Heparin)
In case reports and reviews, three main risk factors have become apparent in patients who
receive neuraxial anesthetics with UFH therapy. They are:
1. Needle placement less than one hour after adminstration of heparin.
2. Traumatic needle placement
3. Concomitant use of other anticoagulants (i.e. ASA) with heparin
It has been recommended that thrice a day SQ heparin is more effective in preventing VTE than
BID dosing of SQ heparin (5000 U). However, BID SQ heparin 5000 units with compression
devices for the legs is just as effective as TID dosing. ASRA discourages TID dosing of SQ
heparin in patients receiving indwellling neuraxial catheters. In patients with a neuraxial
catheter, it is imperative that if they do receive BID SQ heparin 5000 u, that they do not receive
any
other
medication
that
can
effect
coagulation.
ASRA recommends that the SQ heparin be givenafter placement of the block so as to avoid the
potential for block placement during the peak effect of SQ heparin.
LMWH

In the patients who have developed spinal hematomas it is noted that they are often older, female,
and likely have a degree of renal insufficiency. Also, in many cases patients were using other
medications
that
interfere
with
coagulation.
Recommendations:
1. Presence of blood during needle and catheter placement should result in a delay in the
initiation of LMWH dosing for 24 hours.
2. Preoperative LMWH if given should result in delay of at least 10 to 12 hours prior to
needle placement for prophylactic dosages, and greater than 24 hours for treatment
dosages (i.e. 1 mg/kg of enoxaparin).
3. If patients are receiving post operative prophylaxis with LMWH BID, then 1st dose
should be 24 hours after surgery and neuraxial catheters should be removed 2 hours prior
to dosing.
4. If using QD dosing (40 mg enoxeparin) then an indwelling catheter may be maintained
and the 1st dose is given 6 to 8 hours after surgery, while the second dose is given 24
hours after the first.
5. Removal of the catheter in this situation should be done at least 10 to 12 hours after last
dose. No other medications that interfere with coagulation should be given during this
time.
Warfarin
ASRA recommends stopping warfarin 4 to 5 days prior to needle placement and to check the
INR/PT prior to needle placement. This is based on the fact that Factor VII levels return to
normal levels more quickly than Factor II and X levels. Therefore, the INR may return to
baseline quickly after stopping Coumadin, although, coagulation may not be normal due to
decreased
activity
of
Factors
II
and
X.
If Warfarin (Coumadin) is given preoperatively and it has been longer than 24 hours since dose,
then check PT/INR. The INR should be <1.5 for needle placement. ASRA states that an epidural
can remain in place during coumadin therapy, but INR should be checked daily and routine neuro
checks should be done. The epidural catheter can be removed when INR <1.5. Studies indicate
that factor VII acitivity is greater than 40% when INR is greater than 40%. Antiplatelet
medications ASRA has not changed their recommendations here. neuraxial anesthesia is
considered safe in patients taken NSAIDs or ASA as long as they do not have other
coagulopathies. ASRA recommends avoiding needle placement in patients taking Ticlid within
the last 14 days and within the last 7 days for Plavix. For the GP IIb/IIIA inhibitors neuraxial
techniques should be avoided within 24 to 48 hours for abciximab, 4 to 8 hours for eptifibatide
and tirofiban. Fondaparinux This medication is newer and thus there is less experience with this
antithrombotic. The literature supports giving this medication within 6 hours after surgery.
Experience so far is only with single shot neuraxial injections that are atraumatic. The ASRA
guidelines provided some guidance in OB patients which is new. Pregnant patients on oral
anticoagulants should be switched to LMWH or UFH no later than 36 weeks. ASRA
recommends that LMWH should be discontinued 36 hours before induction or cesarean section.

If converted to UFH, this should be discontinued 4 to 6 hours prior to anticipated delivery. Labor
should be induced or a planned cesarean section performed when feasible. Adherence to these
recommendations by obstetricians facilitates the use of neuraxial anesthesia. The area which is
going to generate (and already has) controversy is the last segment that states that:
"recommendations regarding neuraxial techniquest be similarly applied..." for peripheral nerve
blocks and lumbar plexus blocks. Prior to this a breif reveiew of the literature notes that largest
and most significant study was of 670 patients who had lumbar plexus blocks anticoagulated
with warfarin. 36% of the patients had an INR > 1.4 when catheters were discontinued and only
one case of local bleeding was noted in a patient whose INR was 3.0 at time of discontinuation
of the catheter. The bleeding was treated with local pressure and no permanent or severe sequelae
are reported. There are many published cases of clincally significant bleeding in patients
recieving peripheral nerve blocks. In all of these no permanent neurodeficits occurred. In
summary, the ASRA report indicates that with peripheral nerve blocks, the bigger risk is
significant
hemorrhage
rather
than
neurological
damage.
Unfortunately for the practicing clinician, the blanket guidelines published by ASRA indicating
that patients receiving peripheral nerve blocks receive the same treatment as patients receiving
neuraxial anesthesia seems rather extreme. There are certainly cases where the use of LMWH
may make a peripheral nerve catheter unwise (elderly female with mild kidney disease given
BID LMWH). However, other patients, otherwise healthy patient <65 year old undergoing TKA
and difficult to control pain may benefit from a peripheral nerve femoral catheter even though he
is receiving QD 40 mg enoxaparin. Dr. Chelly, from Pittsburgh also takes issue with the most
recent guidelines. He sites a review of 6,935 blocks in over 3,500 patients who received
thromboprophylaxis without interruption none of whom developed major bleeing. (J Athroplasty
2008;23:350-354). Furthermore, Dr. Chelly states that at his institution, they have used
peripheral nerve catheters and thromboprophylaxis with no major bleeding episodes for 15 years.
In the mean time, clinicians will need to consider carefully how they will alter their practice in
light of the new recommendations provided by ASRA. Personally, I can see good reason to use
extra caution when utilizing deep blocks (lumbar plexus blocks) or those in noncompressable
areas (paravertebral blocks), however, more peripheral blocks may be safe even when patients
will receive thromboprophylaxis if the clinician does so with a clear understanding of the risks
and utilizing proper patient selection.