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Antithrombotika

Epidemiology:
  • Risk factors:
    • Anticoagulant use with neuraxial anesthesia, including spinal/epidural puncture, can increase the risk of epidural or spinal hematoma, which can lead to permanent paralysis. The risk of epidural hematoma with neuraxial anesthesia is increased 15-fold with the use of anticoagulant therapy without appropriate precautions (2).
    • This risk can be further increased with the use of postoperative indwelling epidural catheters (1). The risk of hematoma associated with a specific anticoagulant is difficult to accurately assess because the low incidence of hematoma (one epidural hematoma per 150,000 epidural injections) (2).
    • Although the risk of spinal hematoma is unknown, spinal hematoma has been reported in association with the use of fondaparinux (1).
Contraindication: dabigatran is not recommended in patients undergoing anesthesia with postoperative indwelling epidural catheters for total hip- or knee-replacement surgery (1).

Measurements: it has been suggested allowing at least two half-lives (for the specific anticoagulant) to pass before catheter removal, at which point only 25% of the drug remains active.  Allowing a longer interval would only slightly reduce the drug concentration, because elimination slows after this point (2).

Future Risks:
  • With all anticoagulants, the risk of hematoma is increased with concomitant use of medications such as nonsteroidal antiinflammatory drugs, clopidogrel, or other anticoagulants, therefore, management of patients taking these medications requires caution (1).
  • Twice-daily dosing of postoperative low-molecular-weight heparins may be associated with an increased risk of spinal hematoma (1).
Downloads/links: Guidelines bei Patienten mit Antithrombotika: drugs.

References:
  1. Novel Oral Anticoagulants: Implications in the Perioperative Setting. Anesthesiology. 2010;113:726 – 45: full text | pdf | periop.
  2. Selected new antithrombotic agents and neuraxial anaesthesia for major orthopaedic surgery: management strategies. Anaesthesia. 2007;62:1154 – 60: full text | pdf.