Techniques in Regional Anesthesia & Pain Management
Volume 12, Issue 1 , Pages 17-25 , January 2008

Anticoagulation and regional anesthesia in cardiac surgery: safety considerations

  • James E. Baker, MD, FRCPC

      Affiliations

    • Department of Anesthesia, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada
    • ,
  • C. David Mazer, MD, FRCPC

      Affiliations

    • Department of Anesthesia, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada
    • Department of Physiology, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada
    • Interdepartmental Division of Critical Care, University of Toronto, from the Keenan Research Centre in the Li KaShing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada.
    • Corresponding Author InformationAddress reprint requests and correspondence: C. David Mazer, MD, FRCPC, Departments of Anesthesia and Critical Care, St. Michael’s Hospital, 30 Bond Street, Toronto, ON, Canada M5B 1W8.

References 

  1. Gulur P, Nishimori M, Ballantyne JC. Regional anaesthesia versus general anaesthesia, morbidity and mortality. Best Pract Res Clin Anaesthesiol. 2006;20:249–263
  2. Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br Med J. 2000;321:1493
  3. Rigg JR, Jamrozik K, Myles PS, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002;359:1276–1282
  4. Ballantyne JC, Carr DB, de Ferranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg. 1998;86:598–612
  5. Chaney MA. Cardiac surgery and intrathecal/epidural techniques: at the crossroads?. Can J Anaesth. 2005;52:783–788
  6. Chaney MA. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg. 2006;102:45–64
  7. Ho AM, Chung DC, Joynt GM. Neuraxial blockade and hematoma in cardiac surgery: estimating the risk of a rare adverse event that has not (yet) occurred. Chest. 2000;117:551–555
  8. Hemmerling TM, Djaiani G, Babb P, et al. The use of epidural analgesia in cardiac surgery should be encouraged. Anesth Analg. 2006;103:1592;author reply 1592-1593
  9. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79:1165–1177
  10. Tryba M. [Epidural regional anesthesia and low molecular heparin: Pro]. Anasthesiol Intensivmed Notfallmed Schmerzther. 1993;28:179–181
  11. Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003;28:172–197
  12. O’Connor CJ, Tuman KJ. Epidural anesthesia and analgesia for coronary artery bypass graft surgery: still forbidden territory?. Anesth Analg. 2001;93:523–525
  13. Rosen DA, Hawkinberry DW, Rosen KR, et al. An epidural hematoma in an adolescent patient after cardiac surgery. Anesth Analg. 2004;98:966–969
  14. UK MPS. Epidural Emergency, in Education and Publications: UK Casebook. In: 2004;p. 119–120vol. 12(3) Available at: www.medicalprotection.org-the Medical Protection Society Ltd., London, UK
  15. Hanley JA, Lippman-Hand A. If nothing goes wrong, is everything all right? (Interpreting zero numerators). JAMA. 1983;249:1743–1745
  16. Ruppen W, Derry S, McQuay HJ, et al. Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis. BMC Anesthesiol. 2006;6:10
  17. Bracco D, Hemmerling T. Epidural analgesia in cardiac surgery: an updated risk assessment. Heart Surg Forum. 2007;10:E334–E337
  18. Sharma S, Kapoor MC, Sharma VK, et al. Epidural hematoma complicating high thoracic epidural catheter placement intended for cardiac surgery. J Cardiothorac Vasc Anesth. 2004;18:759–762
  19. Royse CF, Soeding PF, Royse AG. High thoracic epidural analgesia for cardiac surgery: an audit of 874 cases. Anaesth Intensive Care. 2007;35:374–377
  20. Yoshinaga A, Sonoda H. [Epidural hematoma caused after epidural catheterization for the coronary artery bypass graft: a case report]. Masui. 2004;53:551–554
  21. Brem SS, Hafler DA, Van Uitert RL, et al. Spinal subarachnoid hematoma: a hazard of lumbar puncture resulting in reversible paraplegia. N Engl J Med. 1981;304:1020–1021
  22. Ruff RL, Dougherty JH. Complications of lumbar puncture followed by anticoagulation. Stroke. 1981;12:879–881
  23. Martinez-Palli G, Sala-Blanch X, Salvado E, et al. Epidural hematoma after epidural anesthesia in a patient with peripheral vascular disease (Case report). Reg Anesth. 1996;21:342–346
  24. Horlocker TT, Wedel DJ, Schroeder DR, et al. Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia. Anesth Analg. 1995;80:303–309
  25. Urmey WF, Rowlingson J. Do antiplatelet agents contribute to the development of perioperative spinal hematoma?. Reg Anesth Pain Med. 1998;23(suppl 2):146–151
  26. Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth. 1996;43:1260–1271
  27. Benzon HT, Wong HY, Siddiqui T, et al. Caution in performing epidural injections in patients on several antiplatelet drugs. Anesthesiology. 1999;91:1558–1559
  28. Horlocker TT. Low molecular weight heparin and neuraxial anesthesia. Thromb Res. 2001;101:V141–V154
  29. Wulf HF. Spinal hematoma: a literature survey with meta-analysis of 613 patients. Neurosurg Rev. 2003;26:51
  30. Kawaguchi S, Tokutomi S. [A case of epidural hematoma associated with epidural catheterization which occurred on 12th days after the last medication of ticlopidine hydrochloride]. Masui. 2002;51:526–528
  31. Mayumi T, Dohi S. Spinal subarachnoid hematoma after lumbar puncture in a patient receiving antiplatelet therapy. Anesth Analg. 1983;62:777–779
  32. Vandermeulen E. Anaesthesia and new antithrombotic drugs. Curr Opin Anaesthesiol. 2005;18:353–359
  33. Patrono C, Coller B, FitzGerald GA, et al. Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(suppl):234S–264S
  34. Liu SS, Mulroy MF. Neuraxial anesthesia and analgesia in the presence of standard heparin. Reg Anesth Pain Med. 1998;23(suppl 2):157–163
  35. Greaves JD. Serious spinal cord injury due to haematomyelia caused by spinal anaesthesia in a patient treated with low-dose heparin. Anaesthesia. 1997;52:150–154
  36. Sandhu H, Morley-Forster P, Spadafora S. Epidural hematoma following epidural analgesia in a patient receiving unfractionated heparin for thromboprophylaxis. Reg Anesth Pain Med. 2000;25:72–75
  37. Odoom JA, Sih IL. Epidural analgesia and anticoagulant therapy (Experience with one thousand cases of continuous epidurals). Anaesthesia. 1983;38:254–259
  38. Wille-Jorgensen P, Jorgensen LN, Rasmussen LS. Lumbar regional anaesthesia and prophylactic anticoagulant therapy (Is the combination safe?). Anaesthesia. 1991;46:623–627
  39. Woolson ST, Robinson RK, Khan NO, et al. Deep venous thrombosis prophylaxis for knee replacement: warfarin and pneumatic compression. Am J Orthop. 1998;27:299–304
  40. Badenhorst CH. Epidural hematoma after epidural pain control and concomitant postoperative anticoagulation. Reg Anesth. 1996;21:272–273

PII: S1084-208X(07)00087-0

doi: 10.1053/j.trap.2007.10.003

Techniques in Regional Anesthesia & Pain Management
Volume 12, Issue 1 , Pages 17-25 , January 2008

Article Tools