Thromboprophylaxis

and
Neuraxial Anesthesia
Don Daniels, M.D.
Chief Anesthesiologist
Brooke Army Medical Center
Fort Sam Houston, TX
 Thromboprophylaxis and Neuraxial Anesthesia

• OBJECTIVES
– Discuss surgical indication for
anticoagulation
– Define surgical vs anesthesia risk/concerns
– Discuss various anticoagulation methods
– Discuss anesthesia options to minimize risk
 Thromboprophylaxis and Neuraxial Anesthesia

• Perioperative hypercoagulability:
– Deep vein thrombosis
• incidence = 25-70%
• local chronic pain, swelling & skin ulceration
– Pulmonary embolism
• Fatality = 0.1-7%
• Chronic thromboembolic pulmonary HTN rare
 Thromboprophylaxis and Neuraxial Anesthesia

• Patients at risk of DVT & PE • Surgeries at risk of DVT & PE

– Advancing age – Major abdominal operations
– Type of operation – Hip or knee arthroplasty
– Duration of operation – Multiple trauma patients
– Prior thromboembolism
– Malignancy
– Varicose veins
– Obesity
– Immobility/Neurologic disease
– Myocardial infarction
– Low cardiac output
– Major trauma
– Oral contraceptives
– Hemostatic abnormalities
 Thromboprophylaxis and Neuraxial Anesthesia

• Prevention of venous thromboembolism

– Antithrombotic drugs
– Inhibition of platelet function
– Prevention of lower extremity venous
pooling with mechanical devices
– Neuraxial anesthesia
– Early ambulation
 Thromboprophylaxis and Neuraxial Anesthesia:
Mechanical Devices
• Intermittent pneumatic compression of
the calves equal to LDH for knee surgery
• Not as effective in hip surgery
 Thromboprophylaxis and Neuraxial Anesthesia:
Anesthesia technique & early ambulation
• Regionals in hip surgery reduce incidence of
DVT by 50% in pts not receiving
thromboprophylaxis
• Combination of regional with
thromboprophylaxis does not provide any
greater DVT protection than
thromboprophylaxis alone. 29 vs 16%
• Early ambulation is a valuable DVT
prophylactic measure
 Thromboprophylaxis and Neuraxial Anesthesia:
1999 ASA Closed Claims Analysis
• 60/4183 (1.4%) claims • All 13 received intraoperative
resulted in para (45) or IV heparin, 5 continued to get
guadriplegia (15) heparin post op
• Most common causes • 11 epidural hematomas
epidural hematoma, chemical occurred after lumbar
injury, anterior spinal artery epidural, 2 after SAB
syndrome and meningitis • 10 diagnosis delayed, post op
• 35 lumbar epidurals, 9 SAB, 4 care judged inappropriate,
thoracic epidural accounted median payment $447,381
for 48/60
• Major factor in 13/48 was
systemic anticoagulation
 Thromboprophylaxis and Neuraxial Anesthesia

• Heparins
– Inactivate coagulation enzymes by binding
to antithrombin III
 Thromboprophylaxis and Neuraxial Anesthesia:
Low Dose Heparin (LDH)
• Surgical • Anesthesia
– DVT reduced by 70% – Neuraxial anesthesia
– PE reduced by 40- considered relative
50% contraindication
– Risk of increased
surgical bleeding =
66%
– Risk of transfusion
<2%
Thromboprophylaxis and Neuraxial Anesthesia:
Heparin after regional. How safe?

• Rao & El-Etr 4461 • 1:150,000 following

LEA w/o sequela epidural
• Sage 7000 LEA w/o • 1:220,000 after spinal
sequela
• Scherer 1071 TEA
w/o sequela
 Thromboprophylaxis and Neuraxial Anesthesia:
SQ Heparin prior to block. Is this safe?

• Lowson & Goodchild - 5000 U SQ 2 hr

prior to neuraxial block is safe
• Similar results noted by Orthopedic
surgeons and general surgeons
• Caution: 3 case reports of spinal
hematoma
 Thromboprophylaxis and Neuraxial Anesthesia:
Identification of Risk Factors with Standard Heparin

• Presence of blood during needle/catheter

placement
• concomitant aspirin therapy
• heparinization within 1 hr
 Guideline for use of Neuraxial Anesthesia in
Patients Receiving SQ or Low Dose Heparin

• Spinal:
– Considered safe 4 hrs after dose
– Withold redose of heparin for 2 hrs after block
• Epidural:
– Get PTT before placement, any manipulation or
removal of catheter
– Considered safe 4 hrs after dose
– Heparin redose at least 2 hrs after ndl or cath
placement, manipulation or removal of cath
 Thromboprophylaxis and Neuraxial Anesthesia:
Low molecular weight heparin (LMWH)
• Unable to acclerate inactivation of thrombin
by AT III
• Catalyze the inhibition of Factor Xa by AT III
• Does not prolong aPTT
• Low protein binding prolongs the plasma half
life
• As effective as LDH in stopping DVT/PE
 Thromboprophylaxis and Neuraxial Anesthesia:
LMWH. Is this safe?

• Wolf 9006 pts - no neurologic sequela

(1993)
• Bergvist review 44 reports (8231 pts) - no
neurologic sequela (1992)
• Pham 1025 pts - no neurologic sequela
(1994)
 Thromboprophylaxis and Neuraxial Anesthesia:
LMWH. Is this safe?

• 1994 - 1 case of neuraxial hematoma

• 1995 - 11 cases of neuraxial hematoma
• 1997 - 30 cases of neuraxial hematoma
• April 1998 - >40 cases
• Fall 1998 - BAMC orthopedic surgeons
unaware of danger of LMWH &
neuraxial anesthesia
 Thromboprophylaxis and Neuraxial Anesthesia:
Identification of Risk Factors with LMWH

• 75% of patients were elderly women

• Multiple or difficult needle placement
• Concomittant administration of an
additional drug affecting coagulation
• Preop administration of LMWH or within
12 hrs of needle placement
• Variability of presenting signs, symptoms
and timing
 Recommendations for Patients receiving LMWH
and Neuraxial Anesthesia

• Monitoring of anti-Xa is not recommended

• Think twice about neuraxial placement when antiplatelet or oral
anticoagulant meds are used in combination with LMWH
• Delay LMWH 24 hrs if blood noted during ndl or cath placement
• A single dose SAB 10-12 hrs after dose may be safer in pts who
received preop LMWH
• Remove cath before initiation of postop LMWH
• If LMWH and continous epidural planned together, use opioid or
dilute local anesthesia and be vigilant
• Cath removal should be 10-12 hrs after dose LMWH. Subsequent
dosing of LMWH should be delayed until 2 hrs after cath removal.
 Thromboprophylaxis and Neuraxial Anesthesia:
Oral Anticoagulants
• Block regeneration of Vitamin K
• Close laboratory monitoring needed
• Optimal PT range 1.3-1.5 times normal
• Risk of increased bleeding above 1.7
times normal
 Oral Anticoagulants and Neuraxial Anesthesia

• Several case reports of neuraxial

hematomas
• Variability of response to warfarin
• Close monitoring of coag status when
spinal or epidural cath used postop
• Prior to removal of cath coag status
should be determined
 Guideline for use of Neuraxial Anesthesia in
Patients Receiving Coumadin

• Spinal:
– Place within 6-8 hrs after preop dose
– PT required morning of surgery
• Epidural:
– Place within 6-8 hrs after preop dose
– PT required morning of surgery
– Remove catheter morning after surgery (POD #1)
– PT required morning of catheter removal
– Neuro checks q 1 hr for next 12 hrs following cath removal
– If INR >1.5, anticoagulation must be reversed prior to removal
of catheter
 Thromboprophylaxis and Neuraxial Anesthesia:
Aspirin/NSAIDs
• Inhibit enzyme cyclooxygenase, reducing
thromboxane A2 production
• Prostacyclin generation capacity minimally
affected by low dose ASA regimens while
completely blocked by larger doses
• Prostacyclin inhibition short lived in NSAIDs,
lifetime of platelets with ASA
• Incidence of DVT/PE reduced with antiplatelet
drugs but not as much as LDH/LMWH
 Antiplatelet Drugs and Neuraxial
Anesthesia: Is it safe?

• Minor hemorrhagic events such as blood

aspirated through needle
• No patients reported with neuraxial
hematoma
 Guideline for use of Neuraxial Anesthesia in
Patients Receiving Aspirin or NSAIDs

• Neuroaxial anesthesia may be offered

• Do not offer if patient taking other
anticoagulant therapies
• Do not offer if patient has pre-existing
coagulopathy
 Neuraxial Hematoma
• Signs may be missed, masked or ignored
• If suspected, CT or MRI immediately
• Decompressive laminectomy within 12
hrs
 Thromboprophylaxis and Neuraxial Anesthesia:
Summary

• Perioperative risk of DVT/PE is high

• Perioperative risk of neuraxial
hematoma is low but an ever present
danger
• Understanding danger of anticoagulation
and neuroaxial anesthesia helps minimize
risk