Neuraxial block and ASRA anticoagulation guidelines

A patient is scheduled for thoracic endovascular aortic repair (TEVAR), and the vascular team is requesting a spinal drain in order to improve postoperative neurologic outcomes. The patient is currently taking warfarin for atrial fibrillation. What parameters must be met based on ASRA anticoagulation guidelines?

A. Discontinue warfarin for 3 days and ensure that that the INR is no greater than 1.5 prior to proceeding, wait a minimum of one hour between spinal drain placement and IV heparin dosing
B. Discontinue warfarin for 3 days and ensure that INR is no greater than 1.1 prior to proceeding, wait a minimum of one hour between spinal drain placement and IV heparin dosing
C. Discontinue warfarin for 5 days and ensure that INR is no greater than 1.5 prior to proceeding, wait a minimum of one hour between spinal drain placement and IV heparin dosing
D. Discontinue warfarin for 5 days and ensure that INR is no greater than 1.1 prior to proceeding, wait a minimum of one hour between spinal drain placement and IV heparin dosing

Show Answer

Correct Answer: D

Explanation:

The ASRA anticoagulation guidelines from 2010 focused more on the use of epidurals for postoperative analgesia as opposed to larger bore spinal drain kits. However, vascular surgery appears to pose a higher risk when compared to other surgeries for the incidence of spinal hematoma. For warfarin use and neuraxial placement, the third consensus statement on anticoagulation guidelines with neuraxial blockade from ASRA in 2010 state that prior to neuraxial block performance, warfarin should be discontinued at least 4-5 days with a normalized INR.

References:

Horlocker TT, Wedel DJ, Rowlingson JC, Enneking K, Kopp SL, Benzon HT, Brown DL, Heit JA, Mulroy MF, Rosenquist RW, Tryba M, Yuan CS. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010;35:64-101.

Gulur P, Tsui B, Pathak R, Koury KM, Lee H. “Retrospective analysis of the incidence of epidural haematoma in patients with epidural catheters and abnormal coagulation parameters.” British J of Anaesthesia 2015;114(5):808-11.

Hide Answer