Cardiac surgery and intrathecal/epidural techniques: at the crossroads?

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

The efficacy of different modes of analgesia in postoperative pain management and early mobilization in postoperative cardiac surgical patients: A systematic review

Cardiac surgery induces severe postoperative pain and impairment of pulmonary function, increases the length of stay (LOS) in hospital, and increases mortality and morbidity; therefore, evaluation of the evidence is needed to assess the comparative benefits of different techniques of pain management, to guide clinical practice, and to identify areas of further research. A systematic search of the Cochrane Central Register of Controlled Trials, DARE database, Joanna Briggs Institute, Google scholar, PUBMED, MEDLINE, EMBASE, Academic OneFile, SCOPUS, and Academic search premier was conducted retrieving 1875 articles. This was for pain management postcardiac surgery in intensive care. Four hundred and seventy-one article titles and 266 abstracts screened, 52 full text articles retrieved for critical appraisal, and ten studies were included including 511 patients. Postoperative pain (patient reported), complications, and LOS in intensive care and the hospital were evaluated. Anesthetic infiltrations and intercostal or parasternal blocks are recommended the immediate postoperative period (4-6 h), and patient-controlled analgesia (PCA) and local subcutaneous anesthetic infusions are recommended immediate postoperative and 24-72 h postcardiac surgery. However, the use of mixed techniques, that is, PCA with opioids and local anesthetic subcutaneous infusions might be the way to go in pain management postcardiac surgery to avoid oversedation and severe nausea and vomiting from the narcotics. Adequate studies in the use of ketamine for pain management postcardiac surgery need to be done and it should be used cautiously.

[Prevention of venous thromboembolism in musculoskeletal surgery]

Musculoskeletal surgery is associated with a high risk of venous thrombosis and pulmonary embolism. The introduction of direct oral anticoagulants (DOAK) has broadened the possibilities for prevention of venous thromboembolism in the course of orthopedic and trauma surgery. Addressing this recent development, the Austrian Societies of Orthopedics and Orthopedic Surgery (ÖGO), Trauma Surgery (ÖGU), Hematology and Oncology (OeGHO) and of Anaesthesiology, Reanimation und Intensive Care Medicine (ÖGARI) have taken the initiative to create Austrian guidelines for the prevention of thromboembolism after total hip and knee replacement, hip fracture surgery, interventions at the spine and cases of minor orthopedic and traumatic surgery. Furthermore, the pharmacology of the DOAK and the pivotal trial data for each of the three currently available substances - apixaban, dabigatran, and rivaroxaban - are briefly presented. Separate chapters are dedicated to "anticoagulation and neuroaxial anesthesia" and "bridging".

Managing anticoagulated patients during neuraxial anaesthesia

The widespread use of central neuraxial block (CNB) and the prevalence of anticoagulation for different indications have led to an inevitable overlap between the two. The most serious complication of CNB in anticoagulated patients is the risk of spinal/epidural haematoma. Performing CNB in these patients is a complex decision that should take into account the twin risks of bleeding and venous/arterial thrombosis if anticoagulation therapies were to be stopped. Various guidelines have been issued to achieve normal haemostasis and thus allow safe administration of CNB. However, the evidence base for many such recommendations is weak, relying mainly on case reports, small studies and pharmacokinetics of the drugs. Given these limitations it is crucial to fully assess individual risk factors and understand anticoagulant pharmacokinetics in order to appropriately set time intervals for catheter insertion/removal. This paper will review traditional and newer anticoagulation/antiplatelet therapies with a view to improving the management of anticoagulated patients undergoing CNB.

The influence of new antithrombotic drugs on regional anesthesia

PURPOSE OF REVIEW

Antithrombotic drugs are known to increase the risk of spinal epidural hematoma after neuraxial blockade. During the last few years, several new anticoagulants have been introduced, some of them more potent than the drugs currently available. More potency, however, may also indicate a higher risk of bleeding.

RECENT FINDINGS

Case series from the last few years indicate that spinal epidural hematoma is more common then previously estimated, with a prevalence from 1: 100,000 in obstetric patients to as high as 1: 3,600 in female orthopedic patients. In order to diminish this risk, most national societies have issued guidelines in which time intervals were established between administration of antithrombotic drugs and performance of neuraxial blockade.

SUMMARY

Guidelines are perceived to be capable of reducing the incidence of spinal epidural hematoma with the inherent risk of permanent paraplegia. These guidelines, however, will only be a valuable aid for clinicians if they are constantly updated and newer antithrombotic drugs are included. Although the resurge of peripheral nerve blocks may diminish patient hazards, deep nerve blocks such as lumbar sympathetic blockade are not devoid of serious complications and should probably be handled in the same way as neuraxial blockade.