NEURAXIAL ANALGESIA

&
ANTICOAGULATION

Charles E Smith MD
 PREVIEW
• Introduction
• Defining the risk
• Regional technique
• Specific Anticoagulants
– therapeutic heparinization
– Low molecular weight heparins (LMWH)
– Oral anticoagulants
– Subcutaneous heparin
– Aspirin and NSAIDs
 Introduction

• Hemorrhagic complications do occur

• Paraplegia after neural blockade

• Increased risk with anticoagulation

 Introduction

• Risk Benefit Ratio

– Pts undergoing surgery receiving
anticoagulants are often the same pts that
benefit from neuraxial blockade
 Introduction

• By understanding the pharmacologic

properties of the anticoagulants the risk of
concurrent neuraxial blockade can be
reduced
Epidural and Intrathecal
Drug Delivery – Anatomy
n Epidural
Intrathecal Space Epidural Space
n Intrathecal

Spinal Cord

From Lif eART, M edic al Clip Art , Copyright © 1998, Lippincott Will iams & Wi lki ns, a Waverly Com pany.
 Defining the Risk

• Spinal hematoma with neuraxial block

– very rare
– need 100,000 for RPDB study
 Defining the Risk

• Sources to determine risk

– case studies without comps after EA or SA
– case studies when EA & SA combined with
anticoagulants without comps
– case reports of comps after EA & SA
– case reports of spontaneous spinal hematoma
 Defining the Risk

• Trybra
– examined case series
• risk after EA 1:150,000
• risk after SA 1:220,000

Tryba M. Epidural regioanl anesth

esia and LMWH: 1993;28:179-81
 Defining the Risk

• Limitations of Tryba
– did not specify risk factors or the use of
perioperative anticoagulants

– Point: spinal hematoma is rare!

 Defining the Risk

• Vandermeulen
– case reports of hematoma after EA or SA
– #61 cases

• Medline search yields 4 more between 1906

and 1996

Vandermeulen EP et al. Anticoagu

lants and spinal-epidural anesthes
 Defining the Risk

• Breakdown
• anticoagulant or clotting d/o in 45/65 (69%)

• Heparin in 32/65 (49%)

– 27 pt with vascular surgery
 Defining the Risk
• Breakdown
• 13 additional pt with variety of other factors
– plts, ETOH, cirrhosis, D70, thrombolytics,ASA

• 6 cases with a combination

• 4 cases with vascular tumors of the epidural
space
• 5 pregnant, 3 had clotting abnormality
 Defining the Risk

• Traumatic tap in 16 (25%)

– 13 with multiple punctures/levels

• 8 of 17 without coag problems noted to

have procedural difficulties
 Defining the Risk

• Therefore 57/65 (86%) had some

reasonable explanation for the complication

• Does this mean we should abandon EA and

SA in pts with perioperative anticoagulants?
 Defining the Risk

• Absolutely Not!

• 14/32 cases followed reasonable guidelines

11 of these 14 had other factors
PAIN
 Defining the Risk

• Spontaneous Spinal Hematoma

– Groen and Ponssen reviewed 199 cases

• 25% associated with anticoagulants

Groen RJ, Ponssen H. The spont

aneous spinal epidural hematoma
 Regional Technique

• Greater risk with EA Vs SA

– 50 with EA and 15 with SA

• Greater risk with catheter insertion

– removal associated with over half
 Therapeutic Heparinization
unfractionated heparin
• UH - polysaccharide that forms a complex with
antithrombin III
• Binds to II a(thrombin)
– lesser extent to Xa, IXa,XI a,XIIa

• 10,000 units prolongs aPTT 2-4 X in 5min

• 1/2 life 90 min
• 4-6 hours effects dissipated
 Therapeutic Heparinization

• Rao and El-Etr - 4,015pts

• 847-SA and 3,164 EA for vasc procedures

• Full heparinization (ACT 2Xbaseline)

– after 1 hour

Roa TL, El-Etr AA. Anticoagulatio

n following placement of epidural
 Therapeutic Heparinization

• Catheters removed in 24hrs

– 1 hour prior to next heparin dose (q6hrs)

• No neurological deficits

• 4 pts with freely aspirated blood from

needle - postponed until the next day
 Therapeutic Heparinization

• Odoom and Sih - 1000 EA for vasc

– on oral anticoagulants pre-op

• systemic heparin bolus and infusion after

X-clamp, not continued post-op
• Catheters removed in 48hrs
• No neurologic sequelae
 Therapeutic Heparinization

• Ruff and Dougherty 7/342 pt s/p LP

– followed by IV heparin for CVA

– all 7 cases heparin started less than 1 hour after

LP (20g needle)
 LMWH
• Fragments of UH - bind to antithrombin III

• However, primary effect on Xa

• Higher bioavailability (100% vs 30%)

• Longer 1/2 -(4-7 hours subQ)

 LMWH

• Xa key to both intrinsic and extrinsic

– coag pathways

– 3:1 Xa to thrombin inhibition activity

– only 60% reversed with protamine

 LMWH

• Lovenox (enoxaparin)
– approved for
• TKA
• THA
• Abdominal surgery
• treatment of DVT not just prophylaxis 1mg/kg q12
 LMWH

• Normiflo
 LMWH

• European experience
– dosing 40mg qd
– guidelines
• SA &EA 8-12 hrs after dose
• delay lovenox 8-12hrs after SA and EA
• don’t start if traumatic EA
• remove catheter 8-12hrs after dose or 1hr prior to
next
 LMWH
• Results - no problems

• Bergqvist 9013 pts with SA & EA

• Estimated in 1992 1 million pts with neuraxial

blockade with only 1 hematoma
• Now 11 reported-majority did not follow
guidelines
 LMWH
• Lovenox - approved in US in 1993
– 30mg BID, “start as soon as possible”
• First year 2 cases of spinal hematoma
• 1995 package insert changed
– delay 12 hours after surgery
• 1997 30 cases “boxed warning”
• 1998 40 cases (prior to guidelines)
• Now 61 reported to Medwatch
 LMWH

• Risk Factors
– elderly females (75%)
– epidural catheters (75%)
– antiplatelet drugs or coumadin in 30%
 LMWH

• Risk Factors

• Timing of LMWH
– known in 20
• 4 pre-op
• 11 within 12hrs of placement
 LMWH

• Onset of neurological symptoms

• Median onset 3 days after LMWH

– 4 - while catheter in place
– 7 - in a few hrs after removal
– 10 - no symptoms 12 hrs or more after removal
 LMWH

• Symptoms
– new onset numbness 14%
– new onset weakness 46%
– bowel and bladder dysfunction
– RARE
• low back or radicular pain
 LMWH
• Recommendations
• Thorough history

• No need to follow anti-Xa levels

• No antiplatelet or oral anticoagulants

• Traumatic - delay LMWH for 24hrs

 LMWH
• Recommendations
• Pre-op Levonox- 12-24 hrs after last dose

• First dose 24hrs post-op

• Catheter removal >12hr after last dose

– next dose in 2 hrs
 LMWH

• Neuraxial blockade over 24 hours

– think again
– really think again
– alternative method of anticoagulation
 Oral Anticoagulants
Warfarin

• Interfers with the metabolic regeneration of

Vitamin K

• Results in hepatic production of defective

II,VII,IX,X
 Oral Anticoagulants
Warfarin
• VII shortest 1/2 life of 6-8hrs

• PT may then be in therapeutic range in 24-

36 hours
– However VII only participates in the extrinsic
pathway
– Full anticoagulation achieved when II and X
suppressed
 Oral Anticoagulants
Warfarin

• Reversible with Vitamin K injections

• FFP (immediate and more reliable)

 Oral Anticoagulants
Warfarin

• Most common scenario

• Orthopedic - low dose after total joint
– Dr. Prevost
 Oral Anticoagulants
Warfarin

• Horlocker -192pts 5mg day of surgery

– All with EA
– Removed after 37hrs (13-96hr)
– PT 13.4 (10.6-25.8)
– No complications

Horlocker TT. Postoperative epidu

ral analgesia and oral anticoag Rx
 Oral Anticoagulants
Warfarin

• Wu - 459 pts 5mg evening of surgery

• PT not prolonged DOS, however, significantly more
prolonged upon removal 14.2 vs 12.1
• > 1.3 X baseline in 159 pts at removal
– THA, TKA
– SA for 47
– EA for 412
– Duration 43.6 hours

Wu c. Oral anticoagulation Prophy

laxis and epidural catheter remov
 Oral Anticoagulants
Warfarin

• Benzon - 60pts

• 5mg po
• 38% with PT > 15sec by 48hrs
 Oral Anticoagulants
Warfarin

• Conclusions

• Safe to maintain epidural catheter for 2-3

days with low dose warfarin
 Oral Anticoagulants
Warfarin

• PT ratio (observed/control) of 1.3 to 1.5

• Different from INR

• observed raised to the power of ISI
– ISI= international sensitivity index
 Oral Anticoagulants
Warfarin

• Recommendations
– stop warfarin for 7days pre-op
– placement with 6-8 hrs of dose
– check PT if dose given >24hrs or if 2nd dose
– check PT on daily basis and before catheter
removal if initial dose was 36hrs before
– Neuro checks during and 24hrs after removal
 Oral Anticoagulants
Warfarin

• Recommendations

– PT < 1.2 and INR < 1.5 proceed

– PT 1.2-1.4x control and INR 1.5-1.75 - think

– 1.5x control and INR >1.75 relatively

contraindicated
 Oral Anticoagulants
Warfarin

• Case Report
• 85 yo WF s/p TKA
• single dose of 10mg Warfarin
• Catheter removed POD #2
• INR 6.3
• BLE paraparesis>>>>>> laminectomy
 Recognition

• Muscle weakness
• Back pain
• Sensory Deficit
• Urinary Retention
• MRI -better
 Treatment

• Early laminectomy
• Good recovery for surgery within 8 hrs of
symptoms
• Longer delay = poorer outcome
 Avoidance

• Acute Pain Service

• Use solutions in low concentrations
• Neuro checks frequently (at least q4)
• 24 hour check after catheter is removed