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Acute warfarin reversal and the use of subarachnoid anaesthesia


Authors: Jindrová Barbora 1;  Kříž Petr 1;  Kvasnička Jan 2;  Burget Filip 3;  Kraus Josef 3;  Stříteský Martin 1;  Michálek Pavel 1
Authors‘ workplace: Klinika anestezie, resuscitace a intenzivní medicíny 1. LF UK v Praze a VFN v Praze 1;  Centrální hematologické laboratoře, Trombotické centrum 1. LF UK v Praze a VFN v Praze 2;  1. chirurgická klinika 1. LF UK v Praze a VFN v Praze 3
Published in: Anest. intenziv. Med., 23, 2012, č. 6, s. 290-294
Category: Anaesthesiology - Original Paper

Overview

Objectives:
The use of neuraxial blocks in patients on warfarin remains controversial. Patients on warfarin may be reversed, according to the Czech Society for Thrombosis and Haemostasis guidelines, using fresh frozen plasma and vitamin K or the concentrate of prothrombin complex factor.

Design:
A cohort of 21 patients, who were a part of a prospective randomized study.

Settings:
Department of Anaesthesia and Intensive Medicine and 1st Department of Surgery, University Hospital.

Materials and methods:
Patients chronically on warfarin (INR > 1.5) indicated for emergency surgical repair of the proximal femur fracture were included in the study. The effect of warfarin was reversed using fresh frozen plasma and vitamin K or prothrombin complex concentrate prior to surgery. Unilateral subarachnoid anaesthesia was chosen as the anaesthetic technique.

Results:
The average INR value was 2.71 (SD 1.31) before reversal and 1.22 (SD 0.14) after reversal. Unilateral subarachnoid anaesthesia with a mixture of 0.5% hyperbaric bupivacaine and morphine was used in all cases. The average number of punctures was 2.23 (SD 1.41). No complications related to the neuraxial block were recorded.

Conclusion:
Given the estimated incidence of spinal haematoma, it would be necessary to include approximately 2.2 million patients for statistically significant confirmation of the safety of subarachnoid anaesthesia in patients following urgent warfarin reversal. However, we consider the use of subarachnoid block as possible if all precautions are fulfilled and the risk/benefit ratio is calculated.

Keywords:
warfarin – acute surgery – subarachnoid anaesthesia


Sources

1. NCEPOD classification of intervention, dostupné online na: http://www.ncepod.org.uk/pdf/NCEPODClassification.pdf., citace 2. 4. 2012.

2. Gumulec, J., Kessler, P., Penka, M., Klodová, D., Králová, S., Brejcha, M., Wrobel, M., Šumná, E., Blatný, J., Klaricová, K., Riedlová, P., Lasota, Z. Krvácivé komplikace při léčbě warfarinem. Doporučení pro klinickou praxi. Sekce pro trombózu a hemostázu ČHS ČLS JEP, 2005.

3. Douketis, J. D., Berger, P. B., Dunn, A. S., Jaffer, A. K., Spyropoulos, A. C., Becker, R. C., Ansell, J. The perioperative management of antithrombotic therapy: American Collegue of chest physicians evidence-based clinical practice guidelines (8th edition). Chest, 2008, 133, S6, p. S299–S339.

4. Horlocker, T. T. Wedel, D. J., Benzon, H., Brown, D. L., Enneking, F. K., Helt, J. A., Mulroy, M. F., Rosenquist, R. W., Rowlingson, J., Tryba, M., Yuan, C. S. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg. Anesth. Pain Med., 2003, 28, 3, p. 172–197.

5. Horlocker, T. T., Wedel, D. J., Rowlingson, J. C., Enneking, F. K., Kopp, S. L., Benzon, H. T., Brown, D. L., Heit, J. A., Mulroy, M. F., Rosenquist, R. W., Tryba, M., Yuan, C. S. et al. Regional anesthesia in the patient receivingantithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (3rd Edition). Reg. Anesth. Pain Med., 2010, 35, 1, p. 64–101.

6. Horlocker, T. T., Wedel, D. J., Rowlingson, J. C., Enneking, F. K. Executive summary: regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (3rd Edition). Reg. Anesth. Pain Med., 2010, 35, 1, p. 102–105.

7. Kříž, P., Jindrová, B., Krška, Z., Kvasnička, J., Trč, T., Stříteský, M. Vliv podání koncentrátu plazmatických faktorů na zkrácení předoperační přípravy warfarinizovaných pacientů se zlomeninou proximálního konce kosti stehenní. Ortopedie, 2012, 5, 6, s. 205–209.

8. Abdel-Wahab, O. I., Healy, B., Dzik, W. H. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion, 2006, 46, 8, p. 1279–1285.

9. Makris, M., Greaves, M., Phillips, W. S., Kitchen, S., Rosendaal, F. R., Preston, E. F. Emergency oral anticoagulation reversal: the relative efficacy of infusions of fresh frosen plasma and clotting factor concetrate on correction of the coagulopathy. Thromb. Haemost., 1997, 77, 3, p. 477–480.

10. Cartmill, M., Dolan, G., Byrne, J. L., Byrne, P. O. Prothrombin complex concentrate for oral anticoagulant reversal in neurosurgical emergencies. Br. J. Neurosurg., 2000, 14, 5, p. 458–461.

11. Fredriksson, K., Norrving, B., Strömblad, L. G. Emergency reversal of anticoagulation after intracerebral hemorrhage. Stroke, 1992, 23, 7, p. 972–977.

12. Josić, D., Hoffer, L., Buchacher, A., Schwinn, H., Frenzel, W., Biesert, L., Klocking, H. P., Hellstern, P., Rokicka-Milewska, R., Klukowska, A. Manufacturing of a prothrombin complex concentrate aiming at low thrombogenicity. Thromb. Res., 2000, 100, 5, p. 433–441.

13. Vandermeulen, E. P., van Aken, H., Vermylen, J. Anticoagulants and spinal-epidural anesthesia. Anesth. Analg., 1994, 79, 6, p. 1165–1177.

14. Bergqvist, D., Lindblat, B., Matzsch, T. Low molecular weight heparin for thromboprophylaxis and epidural/spinal anaesthesia – is there a risk? Acta Anaesthesiol. Scand., 1992, 36, 7, p. 605–609.

15. Parvizi, J., Viskusi, E. R., Frank, H. G., Sharkey, P. F., Hozack, W. J., Rothman, R. R. Can epidural anesthesia and warfarin be coadministered? Clin. Orthop. Relat. Res., 2007, 456, 1, p. 133–137.

16. Kříž P., Jindrová B., Urban M., Zakharchenko M., Kudrna K., Výborný J. Haemodynamic response to different types of anaesthesia for proximal femur fracture osteosynthesis in geriatric patiens. Perioperative Care for Geriatric Patient. Prague, 2009, abstract CD-ROM.

17. Jindrová, B., Kříž, P. Výběr anesteziologické techniky pro chirurgickou intervenci u zlomenin proximálního femuru. XVII. kongres ČSARIM, Zlín, 2010. Anesteziol. intenziv. Med., 2011, 22, 1, s. 44–45.

18. Yamashita, K., Fukusaki, M., Ando, Y., Tanabe, T., Terao, Y., Sumikawa, K. Postoperative analgesia with minidose intrathecal morphine for bipolar hip prothesis in extremely elderly patients. J. Anesth., 2009, 23, 4, p. 504–507.

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