American Society of Interventional Pain Physicians
Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques
Diese Leitlinie umfasst 13 Empfehlungen, 320 Literaturangaben, 18 Tabellen und 7 Abbildungen.
Inhalt auf Englisch
Zusammenfassung
These guidelines provide evidence-based recommendations on the perioperative management of antithrombotic and anticoagulant therapy for patients undergoing interventional pain procedures, stratifying interventions into low, intermediate, and high bleeding risks to minimize adverse events like epidural hematomas and thromboembolisms.
Interventional pain management utilizes minimally invasive procedures to target therapeutics to the central nervous system. Patients on anticoagulant or antithrombotic drugs present a challenge due to bleeding risk accompanying these procedures, while discontinuing these drugs exposes the patient to significant thromboembolic risks.
Kernaussagen
Interventional techniques are classified into low, intermediate, and high bleeding risk categories.
Thromboembolic risks from stopping antithrombotic therapy are generally higher than bleeding risks from continuing it.
Low-dose aspirin should be discontinued 3 days before moderate and high-risk procedures but can be continued for low-risk procedures.
Epidural hematoma requires immediate recognition (severe pain, motor dysfunction) and prompt MRI and surgical evaluation within 12 hours.
Was ist neu in dieser Version
These guidelines update the 2013 ASIPP guidelines. They differ significantly from ASRA guidelines by stratifying procedures differently (e.g., classifying cervical/thoracic epidurals as high-risk) and re-evaluating the balance of thromboembolic risk versus bleeding risk.
Empfehlungen
5.0 Recommendations
Risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk, with upgrades based on other risk factors.
Patientengruppe: Patients undergoing interventional pain procedures
Recognition of the risk of thromboembolic events in patients who interrupt antithrombotic therapy.
Patientengruppe: Patients on antithrombotic therapyWenn: Thromboembolic events
Discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and continuation for low risk or some intermediate risk procedures.
Patientengruppe: Patients taking low dose aspirin
Discontinuation of anticoagulant therapy (warfarin, heparin, dabigatran, rivaroxaban, apixaban, etc.) prior to interventional techniques with individual consideration of pharmacokinetics and individual risk factors increases safety.
Patientengruppe: Patients taking anticoagulant therapy
Diagnosis of epidural hematoma is based on severe pain at the site of injection, rapid neurological deterioration, and MRI, with surgical decompression to avoid neurological sequelae.
Patientengruppe: Patients undergoing spinal proceduresWenn: Epidural hematoma
If thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and discontinued 24 hours before the pain procedure.
Patientengruppe: Patients with high thromboembolic risk
The risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques.
Patientengruppe: Patients on antiplatelet therapy
Multiple variables including anatomic pathology (spinal stenosis, ankylosing spondylitis), procedural risk levels, observed bleeding, and multiple attempts increase the risk for bleeding complications.
Patientengruppe: Patients with anatomic pathologiesWenn: Bleeding complications
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