Waiting time for NOACs and neuraxial

[deleted875186]

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So you have an adult that would benefit from a SAB or epidural for an elective surgery, is on a NOAC for afib, the cardiologist told them stop 2 days ago.

Would you do the neuraxial procedure?

If you look at the full updated ASRA guidelines it is a loose timeframe. It states in patients, non elderly, no CKD, taking 5 mg BID, a time of 40-72 hours is recommended. Somehow, in the the ASRA app, it states a flat out 72 hours? What do most people do, default to the most conservative timeframe?

 

[BLADEMDA]

Most people in PP are conservative and use 72 hours. That said, you can use 48 hours for non elderly with good CR clearance greater than 50.

https://depts.washington.edu/anticoag/home/sites/default/files/Management%20of%20Antithrombotic%20Therapy%20for%20Neuraxial%20and%20Peripheral%20Nerve%20Procedures.pdf

 

[jope]

It is pretty rare that someone must absolutely have a neuraxial anesthetic. It take a huge indication (ie. severe pulmonary cripple) for me to knowingly violate ASRA guidelines for an elective case.

 

[BLADEMDA]

https://kr.ihc.com/ext/Dcmnt?ncid=520499512&tfrm=default

I typically use 72 hours except for Pradaxa which is longer like 5-6 days.

 

[BLADEMDA]

 

[deleted875186]

Ok, so how about you have a healthy adult, going to get a thoracotomy for some type of tumor, postop pain and pulmonary status would greatly benefit from an epidural but they stopped their Eliquis 48 hours ago?

 

[BLADEMDA]

These days I mostly see Xarelto and Eliquis (besides Plavix or Effient). The Cardiologists typically stop them 3 days prior to surgery. I will do a single shot SAB for a patient who has D/C'd Plavix for 5 days but I require a PLAVIX NOW test. For Effient the D/C time is 7 days.

Lab Test Directory

Lab Test Directory

www.uwhealth.org

 

[BLADEMDA]

Ok, so how about you have a healthy adult, going to get a thoracotomy for some type of tumor, postop pain and pulmonary status would greatly benefit from an epidural but they stopped their Eliquis 48 hours ago?

I do an ESP on those patients. Sure, they aren't as good but they do work and are very safe. Others would do a Thoracic Epidural on a healthy adult off Xarelto/Eliquis for 48 hours.

 

[BLADEMDA]

The erector spinae plane (ESP) block: A pooled review of 242 cases - PubMed

To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.

www.ncbi.nlm.nih.gov

Best to place a catheter as a single shot won't last very long. Even Exparel single shots won't give analgesia beyond 24 hours.

https://www.researchgate.net/publication/314197863_Continuous_Erector_Spinae_Plane_Block_for_Rescue_Analgesia_in_Thoracotomy_After_Epidural_Failure_A_Case_Report

 

[BLADEMDA]

https://els-jbs-prod-cdn.literatumonline.com/cms/attachment/bb066ba3-3d81-4a29-a9f3-7fceee32c873/gr1.jpg

 

[BLADEMDA]

https://www.jcvaonline.com/article/S1053-0770(18)30272-6/fulltext

In summary, many practical and theoretical advantages of this block, including technical simplicity, direct ultrasound visualization, ability to perform the procedure under general anesthesia, less concern in case of a hematoma in an anticoagulated patient, and potentially less sympathectomy-related hypotension, make it an appealing modality in the lung transplant population and add to the very important component of patient care.

ESP work best with a LOT Of volume. I prefer low continuous infusions with large bolus infusions of dilute local. The problem with ESPs is that they require VOLUME to get good analgesia.

 

[deleted171991]

View attachment 281469

Where is this from?

 

[BLADEMDA]

I honestly think that we are too conservative when it comes to this issue but we live in a society filled with malpractice lawyers. That means we are very very cautious.

Here is one from University of Colorado indicating their time frames.

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/surgery/divisions/Trauma/Trauma-at-UCH/Documents/STICU-Protocols/Neuraxial-Anticoag-Guide.pdf

 

[BLADEMDA]

Based on half lives Xarelto appears to be the safest of the commonly used Oral Anticoagulants if one desires to do a Neuraxial block after stopping the drug for 48 hours.

 

[deleted171991]

Whenever in doubt (e.g. CKD), I would advise people to postpone the block for postop, after they see (the lack of) intraop oozing. I've had a couple of cases where I was happy I had done so, even after 3 days.

Anticoagulant reversal

CONTENTS getting started General considerations Pre-procedure coagulation management for common procedures common reversal situations Approach to warfarin reversal Urgent reversal Non-urgent supratherapeutic INR Approach to DOAC reversal Dabigatran Factor Xa inhibitors (riveroXABAN, apiXABAN...

emcrit.org

In the end, it's a matter of risks vs benefits. I tend to have a very honest discussion with the patient and family.

 

[deleted875186]

Whenever in doubt (e.g. CKD), I would advise people to postpone the block for postop, after they see (the lack of) intraop oozing. I've had a couple of cases where I was happy I had done so, even after 3 days.

Anticoagulant reversal

CONTENTS getting started General considerations Pre-procedure coagulation management for common procedures common reversal situations Approach to warfarin reversal Urgent reversal Non-urgent supratherapeutic INR Approach to DOAC reversal Dabigatran Factor Xa inhibitors (riveroXABAN, apiXABAN...

emcrit.org

In the end, it's a matter of risks vs benefits. I tend to have a very honest discussion with the patient and family.

This is very true. Can always do a rescue block.