Skip to main content
SpringerLink
Log in

Coagulation and Regional Anesthesia

  • Chapter
  • First Online:
Essentials of Blood Product Management in Anesthesia Practice

  • 859 Accesses

Abstract

In the field of anesthesiology, we take care of a broad demographic of patients with various medical conditions. Certainly, it is common practice to be aware of the medical history of our individual patients, as well as their medication lists. Yet, it is just as important to have a strong understanding of the indications of these medications and the implications they may have on anesthetic care. A medication class that has distinct implications on regional anesthesia is anticoagulants.

The medical conditions that benefit from anticoagulation are those that are associated with a predisposition of increased thromboembolic risk. Ailments reflective of this notion include atrial fibrillation, recent venous/arterial thromboembolism, valvular heart disease, and prosthetic heart valves [1]. From 2009 to 2014, anticoagulation treatment visits increased from 2.05 million to 2.83 million. Similarly, the number of direct oral anticoagulant (DOAC) visits continues to rise since their debut in 2010 [2]. As the realm of anticoagulation continues to expand, the perioperative management of patients receiving anticoagulants remains of importance. This chapter will discuss the management of regional anesthesia for patients on anticoagulation. We will provide a brief overview on the mechanism of anticoagulants and focus on a review of the current guidelines of regional anesthesia in patients receiving antithrombotic or thrombolytic therapy, as well as a brief analysis of relevant controversies and uncertainties.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Stults BM, Dere WH, Caine TH. Long-term anticoagulation. Indications and management. West J Med. 1989;151(4):414–29.

    CAS  PubMed  PubMed Central  Google Scholar 

  2. Barnes GD, Lucas E, Alexander GC, Goldberger ZD. National trends in ambulatory oral anticoagulant use. Am J Med. 2015;128(12):1300–5.e2.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Palta S, Saroa R, Palta A. Overview of the coagulation system. Indian J Anaesth. 2014;58(5):515–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Periayah MH, Halim AS, AZM S. Mechanism action of platelets and crucial blood coagulation pathways in hemostasis. Int J Hematol Oncol Stem Cell Res. 2017;11(4):319–27.

    PubMed  PubMed Central  Google Scholar 

  5. Smith SA, Travers RJ, Morrissey JH. How it all starts: initiation of the clotting cascade. Crit Rev Biochem Mol Biol. 2015;50(4):326–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Hall JE. Hemostasis and blood coagulation. In: Guyton and hall textbook of medical physiology: enhanced e-book. 11th ed. Philadelphia: Elsevier Health Sciences; 2010. p. 457–9.

    Google Scholar 

  7. Kumar V, Abbas AK, Fausto N, Aster JC. Hemodynamic disorders, thromboembolic disease and shock. In: Robbins and Cotran pathologic basis of disease. 8th ed. Philadelphia: Saunders Elsevier; 2010. p. 118–20.

    Google Scholar 

  8. Chaudhry R, Babiker HM. Physiology, coagulation pathways. [Updated 2019 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482253/.

  9. Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fourth edition). Reg Anesth Pain Med. 2018;43(3):263–309.

    Article  PubMed  Google Scholar 

  10. Torpy JM, Lynm C, Golub RM. JAMA patient page. Regional anesthesia. JAMA. 2011;306(7):781.

    Article  CAS  PubMed  Google Scholar 

  11. Smith LM, Cozowicz C, Uda Y, et al. Neuraxial and combined neuraxial/general anesthesia compared to general anesthesia for major truncal and lower limb surgery: a systematic review and meta-analysis. Anesth Analg. 2017;125:1931.

    Article  PubMed  Google Scholar 

  12. Johnson RL, Kopp SL, Burkle CM, et al. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth. 2016;116(2):163–76.

    Article  CAS  PubMed  Google Scholar 

  13. Lirk P, Hollmann MW. Outcome after regional anesthesia: weighing risks and benefits. Minerva Anestesiol. 2014;80(5):610–8.

    CAS  PubMed  Google Scholar 

  14. Ash EA. Chapter 119. Safety in regional anesthesia. In: Atchabahian A, Gupta R, editors. The anesthesia guide. New York: McGraw-Hill; 2013. p. 499–504.

    Google Scholar 

  15. Horlocker T, Kopp S. Epidural hematoma after epidural blockade in the United States: it’s not just low molecular heparin following orthopedic surgery anymore. Anesth Analg. 2013;116(6):1195–7.

    Article  PubMed  Google Scholar 

  16. Benzon HT. Chapter 8. Regional anesthesia in the anticoagulated patient. In: Hadzic A, editor. Hadzic's peripheral nerve blocks and anatomy for ultrasound-guided regional anesthesia. 2nd ed. New York: McGraw-Hill; 2012. p. 107–13.

    Google Scholar 

  17. Enneking FK, Huntoon MA. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: if only the data were produced in a river not a pond! Reg Anesth Pain Med. 2018;43(3):223–4.

    Article  PubMed  Google Scholar 

  18. Regional anaesthesia and patients with abnormalities of coagulation: the Association of Anaesthetists of Great Britain & Ireland The Obstetric Anaesthetists’ Association Regional Anaesthesia UK. Anaesthesia. 2013;68(9):966–72.

    Google Scholar 

  19. Gogarten W, Vandermeulen E, Van Aken H, et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010;27(12):999–1015.

    Article  CAS  PubMed  Google Scholar 

  20. Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med. 1998;23(6 Suppl 2):129–34.

    CAS  PubMed  Google Scholar 

  21. Hirsh J, Warkentin TE, Shaughnessy SG, et al. Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety. Chest. 2001;119(1 Suppl):64S–94S.

    Article  CAS  PubMed  Google Scholar 

  22. Gray E, Hogwood J, Mulloy B. The anticoagulant and antithrombotic mechanisms of heparin. Handb Exp Pharmacol. 2012;207:43–61.

    Article  CAS  Google Scholar 

  23. Merli GJ, Groce JB. Pharmacological and clinical differences between low-molecular-weight heparins: implications for prescribing practice and therapeutic interchange. P T. 2010;35(2):95–105.

    PubMed  PubMed Central  Google Scholar 

  24. Hirsh J, Bauer KA, Donati MB, Gould M, Samama MM, Weitz JI. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6 Suppl):141S–59S.

    Article  CAS  PubMed  Google Scholar 

  25. Center for Drug Evaluation and Research. FDA drug safety communication: updated recommendations to decrease risk of spinal column bleeding and paralysis in patients on low molecular weight heparins. U.S. Food and Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-updated-recommendations-decrease-risk-spinal-column-bleeding-and#tabs-3.

  26. Crader MF, Johns T, Arnold JK. Warfarin drug interactions. [Updated 2019 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441964/.

  27. Hanley JP. Warfarin reversal. J Clin Pathol. 2004;57(11):1132–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Franchini M, Lippi G. Prothrombin complex concentrates: an update. Blood Transfus. 2010;8(3):149–54.

    PubMed  PubMed Central  Google Scholar 

  29. Reynolds NA, Perry CM, Scott LJ. Fondaparinux sodium: a review of its use in the prevention of venous thromboembolism following major orthopaedic surgery. Drugs. 2004;64(14):1575–96.

    Article  CAS  PubMed  Google Scholar 

  30. Cappelleri G, Fanelli A. Use of direct oral anticoagulants with regional anesthesia in orthopedic patients. J Clin Anesth. 2016;32:224–35.

    Article  CAS  PubMed  Google Scholar 

  31. Kaushal M, Rubin RE, Kaye AD, Gritsenko K. Anticoagulation and neuraxial/peripheral anesthesia. Anesthesiol Clin. 2017;35(2):e21–39.

    Article  PubMed  Google Scholar 

  32. Van den heuvel JM, Hövels AM, Büller HR, Mantel-teeuwisse AK, De boer A, Maitland-van der Zee AH. NOACs replace VKA as preferred oral anticoagulant among new patients: a drug utilization study in 560 pharmacies in The Netherlands. Thromb J. 2018;16:7.

    Article  PubMed  PubMed Central  Google Scholar 

  33. De caterina R, Ageno W, Agnelli G, et al. The non-vitamin K antagonist oral anticoagulants in heart disease: section V-special situations. Thromb Haemost. 2019;119(1):14–38.

    Article  PubMed  Google Scholar 

  34. Demir M. Coagulation testing for new oral anticoagulants. J Atr Fibrillation. 2015;8(3):1089.

    PubMed  PubMed Central  Google Scholar 

  35. Abed HS, Kilborn MJ, Chen V, Sy RW. Reversal agents in the era of NOACs. J Atr Fibrillation. 2017;10(4):1634.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Levy JH, Douketis J, Weitz JI. Reversal agents for non-vitamin K antagonist oral anticoagulants. Nat Rev Cardiol. 2018;15(5):273–81. https://doi.org/10.1038/nrcardio.2017.223.

    Article  CAS  PubMed  Google Scholar 

  37. Rowe AS, Dietrich SK, Phillips JW, Foster KE, Canter JR. Activated prothrombin complex concentrate versus 4-factor prothrombin complex concentrate for vitamin K-antagonist reversal. Crit Care Med. 2018;46(6):943–8.

    Article  CAS  PubMed  Google Scholar 

  38. Turecek PL, Váradi K, Gritsch H, Schwarz HP. FEIBA: mode of action. Haemophilia. 2004;10(Suppl 2):3–9.

    Article  CAS  PubMed  Google Scholar 

  39. Baker WF. Thrombolytic therapy: current clinical practice. Hematol Oncol Clin North Am. 2005;19(1):147–81, vii.

    Article  PubMed  Google Scholar 

  40. Ali MR, Salim Hossain M, Islam MA, et al. Aspect of thrombolytic therapy: a review. Scientific World Journal. 2014;2014:586510.

    PubMed  Google Scholar 

  41. Vela Vásquez RS, Peláez Romero R. Aspirin and spinal haematoma after neuraxial anaesthesia: myth or reality? Br J Anaesth. 2015;115(5):688–98.

    Article  PubMed  CAS  Google Scholar 

  42. Wijeyeratne YD, Heptinstall S. Anti-platelet therapy: ADP receptor antagonists. Br J Clin Pharmacol. 2011;72(4):647–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Schneider DJ. Anti-platelet therapy: glycoprotein IIb-IIIa antagonists. Br J Clin Pharmacol. 2011;72(4):672–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Wong WW, Gabriel A, Maxwell GP, Gupta SC. Bleeding risks of herbal, homeopathic, and dietary supplements: a hidden nightmare for plastic surgeons? Aesthet Surg J. 2012;32(3):332–46.

    Article  PubMed  Google Scholar 

  45. Hirsch GE, Viecili PRN, De almeida AS, et al. Natural products with antiplatelet action. Curr Pharm Des. 2017;23(8):1228–46.

    Article  CAS  PubMed  Google Scholar 

  46. Tsai TP. Chapter 12. Anticoagulation, antiplatelet medications. In: Atchabahian A, Gupta R, editors. The anesthesia guide. New York: McGraw-Hill; 2013. p. 50.

    Google Scholar 

  47. Gilbert GJ. Ginkgo biloba. Neurology. 1997;48:1137.

    Article  CAS  PubMed  Google Scholar 

  48. Lee A, Chui PT, Aun CS, Lau AS, Gin T. Incidence and risk of adverse perioperative events among surgical patients taking traditional Chinese herbal medicines. Anesthesiology. 2006;105:454–61.

    Article  PubMed  Google Scholar 

  49. Moss J, Yuan CS. Herbal medicines and perioperative care. Anesthesiology. 2006;105:441–2.

    Article  PubMed  Google Scholar 

  50. Doan L. Chapter 163. Management of continuous peripheral nerve blocks. In: Atchabahian A, Gupta R, Atchabahian A, Gupta R, editors. The anesthesia guide. New York: McGraw-Hill; 2013. p. 690–1.

    Google Scholar 

  51. James AH. Pregnancy and thrombotic risk. Crit Care Med. 2010;38(2 Suppl):S57–63.

    Article  PubMed  Google Scholar 

  52. Leffert L, Butwick A, Carvalho B, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants. Anesth Analg. 2018;126(3):928–44.

    Article  PubMed  Google Scholar 

  53. ACOG Practice Bulletin No. 196: Thromboembolism in pregnancy. Obstet Gynecol. 2018;132(1):e1–e17.

    Google Scholar 

  54. Leffert LR, Dubois HM, Butwick AJ, Carvalho B, Houle TT, Landau R. Neuraxial anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low-molecular-weight heparin: a systematic review of spinal epidural hematoma. Anesth Analg. 2017;125(1):223–31.

    Article  PubMed  Google Scholar 

  55. Lameijer H, Aalberts JJJ, Van Veldhuisen DJ, Meijer K, Pieper PG. Efficacy and safety of direct oral anticoagulants during pregnancy; a systematic literature review. Thromb Res. 2018;169:123–7.

    Article  CAS  PubMed  Google Scholar 

  56. Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology. 2004;101(4):950–9.

    Article  CAS  PubMed  Google Scholar 

  57. Lee LA, Posner KL, Domino KB, Caplan RA, Cheney FW. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology. 2004;101(1):143–52.

    Article  PubMed  Google Scholar 

  58. Nelson A, Benzon HT, Jabri RS. Diagnosis and management of spinal and peripheral nerve hematoma. In: Hadzic A, editor. Hadzic’s textbook of regional anesthesia and acute pain management. 2nd ed. New York: McGraw-Hill; 2012.

    Google Scholar 

  59. Nam KH, Choi CH, Yang MS, Kang DW. Spinal epidural hematoma after pain control procedure. J Korean Neurosurg Soc. 2010;48(3):281–4.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Tailor J, Dunn IF, Smith E. Conservative treatment of spontaneous spinal epidural hematoma associated with oral anticoagulant therapy in a child. Childs Nerv Syst. 2006;22(12):1643–5.

    Article  PubMed  Google Scholar 

  61. Zhang S, Geng F, Wang J, Zhang Z, Du C. Rapid recovery of spontaneous spinal epidural hematoma without surgical treatment: case report and literature review. World Neurosurg. 2018;115:216–9.

    Article  PubMed  Google Scholar 

  62. Raasck K, Habis AA, Aoude A, et al. Spontaneous spinal epidural hematoma management: a case series and literature review. Spinal Cord Ser Cases. 2017;3:16043.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Weill Cornell Medicine, Department of Anesthesiology, New York, NY, USA

    Chrissy Cherenfant

  2. NYU Langone Health, NYU Langone Orthopedic Hospital, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York, NY, USA

    Uchenna Umeh

Authors
  1. Chrissy Cherenfant
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Uchenna Umeh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Uchenna Umeh .

Editor information

Editors and Affiliations

  1. NYU-Grossman School of Medicine, Department of Anesthesiology, New York, NY, USA

    Corey S. Scher

  2. Departments of Anesthesiology and Pharmacology Toxicology, and Neurosciences, Louisiana State University School of Medicine-Shreveport, Shreveport, LA, USA

    Alan David Kaye

  3. Department of Anesthesiology and Perioperative Medicine, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA

    Henry Liu

  4. NYU Grossman School of Medicine, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York, NY, USA

    Seth Perelman

  5. NYU-Grossman School of Medicine, Department of Anesthesiology, New York, NY, USA

    Sarah Leavitt

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Cherenfant, C., Umeh, U. (2021). Coagulation and Regional Anesthesia. In: Scher, C.S., Kaye, A.D., Liu, H., Perelman, S., Leavitt, S. (eds) Essentials of Blood Product Management in Anesthesia Practice. Springer, Cham. https://doi.org/10.1007/978-3-030-59295-0_44

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-59295-0_44

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-59294-3

  • Online ISBN: 978-3-030-59295-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation