When is it safe to do regional anaesthesia ? Christian Fenger-Eriksen MD, Ph.D Operation / Intensiv Nord Aarhus Universitetshospital chfen@dadlnet.dk

Disclosure CSL Behring LFB Novo Nordisk TEM International

Risk and type of regional anaesthesia W. Harrop-Griffiths et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: pages 966-72

Regional anaesthesia – the problem Normal haemostasis Risk of haematoma after neuraxial blockade 0.85 per 100 000 Risk Disturbed haemostasis Accurate estimates difficult Higher ?

1993 First LMWH launched in US 1998 40 spinal haematoma reported

Bleeding risk and patient factors Medication induced disturbed haemostasis Clopidogrel, Rivaroxaban, heparin etc Expected impaired haemostais Trauma, sepsis, liver insufficiency, etc Unexpected impaired haemostasis Unknown (mild)haemophilia, von Willebrand disease etc Wait Measure Ask the patient

Medication induced disturbed haemostasis Wait approach Basic pharmacokinetic rules / case reports Beware renal/liver insufficiency

Rivaroxaban Different recommendations From discontination to procedure From procedure to resumption of drug Nordic SSAI 8 – 10 h 48 h 24 h ESA 5 – 9 h 22 -36 h 4 -6 h ASRA 9 – 13 h 72 h

Laboratory test Can we predict bleeding Central vein cannulation 580 procedures INR ≥ 1,5 Platelet count below 150 x 10 9 Major bleeding in one patient (0,2 %) Fisher NC, et al Intensive Care Med 1999;25:481-5

Laboratory test Can we predict bleeding PPV (prolonged clotting time) 0.03 – 0.22 Chee YL et al British Journal of Haematology 2008, 140, 496–504

Bleeding history 702 patients 9.4 % abnormal laboratory tests 30.5 % reported suspicious bleeding history 15 patients (3 %) showed moderate bleeding 12 patients (2.4 %) severe postoperative bleeding PPV of coagulation screening 6.8 % PPV history alone predicted 9.2 % Eberl W et al Klin Padiatr. 2005 Jan-Feb;217(1):20-4.

Bleeding history 500 healthy adults 25% of subjects reported epistaxis ASH Education Book ASH Education Book Bleeding history 500 healthy adults 25% of subjects reported epistaxis 18% prolonged bleeding after a tooth extraction 47% of women reported heavy menstrual bleeding O´Brien et al Ash Education Book, December 8, 2012 no 1, 152-56

Conclusion I Risk associated with regional anaesthesia in patients antithrombotic drugs Spinal / epidural / deep blocks The safe way No anticoagulation drugs + No bleeding history Normal haemostasis parameters = OK

Conclusion II Risk/benefit An abnormality of coagulation – severe or not – is always a relative contraindication to the use of a regional anaesthetic technique

When is it safe to do regional anaesthesia ? Christian Fenger-Eriksen MD, Ph.D Operation / Intensiv Nord Aarhus Universitetshospital chfen@dadlnet.dk