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

2. Disclosure
CSL Behring
LFB
Novo Nordisk
TEM International

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

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

5. 1993 First LMWH launched in US
spinal haematoma reported

6. 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

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

8. 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 h
4 -6 h
ASRA
9 – 13 h
72 h

9. 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

10. 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

11. 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 Jan-Feb;217(1):20-4.

12. 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,

13. 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

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

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