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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition)

Regional Anesthesia and Pain Medicine
April 2018 - Volume 43 - Issue 3 - p 263–309
doi: 10.1097/AAP.0000000000000763
Horlocker, Terese, T.; Vandermeuelen, Erik; Kopp, Sandra, L.; Gogarten, Wiebke; Leffert, Lisa, R.; Benzon, Honorio, T.

Evolving standards for the prevention of perioperative venous thromboembolism (VTE) and the introduction of increasingly potent antithrombotic medications have resulted in concerns regarding the heightened risk of neuraxial bleeding. Furthermore, societies and organizations seeking to address these concerns through guidelines in perioperative management have issued conflicting recommendations. In response to these patient safety issues and the need for a more international approach to management, the American Society of Regional Anesthesia and Pain Medicine (ASRA), in conjunction with the European Society of Anaesthesiology (ESA), convened its Fourth Consensus Conference on Regional Anesthesia and Anticoagulation. Portions of the material presented here were published in the 1998, 2003, and 2010 ASRA Consensus Documents as well as the 2010 ESA Guidelines.1–8 The information has been updated to incorporate data available since the time of its publication.

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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition) Erratum

  • Recommendation 3.4.1 on page 272 is a new recommendation. The Remarks following the recommendation should read: “This is a new recommendation. Earlier guidelines did not specify a time interval between SC administration of UFH and neuraxial blockade. These recommendations are based on the pharmacology of SC 5000-U dose of UFH, which results in a significant anticoagulant effect that persists 4 to 6 hours after administration.”
  • Recommendation 3.4.4 on page 272 should be corrected to read: “Recommendation 3.4.4 Postoperative low-dose UFH. There is no contraindication to maintaining neuraxial catheters in the presence of low-dose UFH. We suggest catheter removal occur 4 to 6 hours after heparin administration. Subsequent heparin administration may occur immediately after neuraxial blockade or catheter removal (grade 2C). Remarks: This recommendation has been updated. Previously a 1-hour time interval was recommended between neuraxial blockade or catheter removal and administration of low-dose SC UFH. These recommendations were based on the pharmacology of SC 5000-U dose of UFH, which does not result in a significant anticoagulant effect for least 1 hour after administration.”
  • Recommendation 13.5 on page 286 should state “13.5 Platelet GP IIb/IIIa. The platelet GP IIb/IIIa inhibitors exert a profound effect on platelet aggregation. Following administration, the time to normal platelet aggregation is 24 to 48 hours for abciximab and 4 to 8 hours for eptifibatide and tirofiban.”