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I had an inpatient that I was considering a PNB on, and I saw that she was on fondaparinux for DVT prophylaxis. I thought the ASRA guidelines would treat it like Lovenox, but I was wrong.
Fondaparinux
Fondaparinux, an injectable synthetic pentasaccharide, was approved in December 2001. The FDA released fondaparinux (Arixtra) with a black box warning similar to that of the LMWHs and heparinoids. Fondaparinux produces its antithrombotic effect through factor Xa inhibition. The plasma half-life of fondaparinux is 21 hrs, allowing for single-daily dosing, with the first dose administered 6 hrs postoperatively.179 Investigators reported a spinal hematoma among the initial dose-ranging study (at a dose that was subsequently determined to be twice that required for thromboprophylaxis).179,180 No additional spinal hematomas were reported in the combined series of 3600 patients who underwent spinal or epidural anesthesia in combination with fondaparinux thromboprophylaxis. However, the conditions for performance of neuraxial block were strictly controlled. Patients were included in subsequent clinical trials only if needle placement was atraumatic and accomplished on the first attempt. In addition, indwelling epidural catheters were removed 2 hrs before fondaparinux administration. These strict parameters suggested that neuraxial blockade in patients with planned fondaparinux thromboprophylaxis may not be feasible in clinical practice. For example, in a prospective series, less than 40% of neuraxial blocks were successful with 1 pass.35 A recent series of 1631 patients undergoing continuous neuraxial or deep peripheral block reported no serious hemorrhagic complications. However, the catheters were removed 36 hrs after the last dose of fondaparinux, and subsequent dosing was delayed for 12 hrs after catheter removal.181 Although these results are reassuring, the deviation from the manufacturer's suggested dosing guidelines is of concern.
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9.0 Anesthetic Management of the Patient Receiving Fondaparinux
The actual risk of spinal hematoma with fondaparinux is unknown. Consensus statements are based on the sustained and irreversible antithrombotic effect, early postoperative dosing, and the spinal hematoma reported during initial clinical trials. Close monitoring of the surgical literature for risk factors associated with surgical bleeding may be helpful in risk assessment and patient management.
9.1 Until further clinical experience is available, performance of neuraxial techniques should occur under conditions used in clinical trials (single-needle pass, atraumatic needle placement, avoidance of indwelling neuraxial catheters). If this is not feasible, an alternate method of prophylaxis should be considered.
I just posted this in case anyone else has had to deal with this. Anyone doing neuraxial with patients on fondaparinux?
Fondaparinux
Fondaparinux, an injectable synthetic pentasaccharide, was approved in December 2001. The FDA released fondaparinux (Arixtra) with a black box warning similar to that of the LMWHs and heparinoids. Fondaparinux produces its antithrombotic effect through factor Xa inhibition. The plasma half-life of fondaparinux is 21 hrs, allowing for single-daily dosing, with the first dose administered 6 hrs postoperatively.179 Investigators reported a spinal hematoma among the initial dose-ranging study (at a dose that was subsequently determined to be twice that required for thromboprophylaxis).179,180 No additional spinal hematomas were reported in the combined series of 3600 patients who underwent spinal or epidural anesthesia in combination with fondaparinux thromboprophylaxis. However, the conditions for performance of neuraxial block were strictly controlled. Patients were included in subsequent clinical trials only if needle placement was atraumatic and accomplished on the first attempt. In addition, indwelling epidural catheters were removed 2 hrs before fondaparinux administration. These strict parameters suggested that neuraxial blockade in patients with planned fondaparinux thromboprophylaxis may not be feasible in clinical practice. For example, in a prospective series, less than 40% of neuraxial blocks were successful with 1 pass.35 A recent series of 1631 patients undergoing continuous neuraxial or deep peripheral block reported no serious hemorrhagic complications. However, the catheters were removed 36 hrs after the last dose of fondaparinux, and subsequent dosing was delayed for 12 hrs after catheter removal.181 Although these results are reassuring, the deviation from the manufacturer's suggested dosing guidelines is of concern.
Back to Top | Article Outline
9.0 Anesthetic Management of the Patient Receiving Fondaparinux
The actual risk of spinal hematoma with fondaparinux is unknown. Consensus statements are based on the sustained and irreversible antithrombotic effect, early postoperative dosing, and the spinal hematoma reported during initial clinical trials. Close monitoring of the surgical literature for risk factors associated with surgical bleeding may be helpful in risk assessment and patient management.
9.1 Until further clinical experience is available, performance of neuraxial techniques should occur under conditions used in clinical trials (single-needle pass, atraumatic needle placement, avoidance of indwelling neuraxial catheters). If this is not feasible, an alternate method of prophylaxis should be considered.
I just posted this in case anyone else has had to deal with this. Anyone doing neuraxial with patients on fondaparinux?
