your limit has been reached. plz Donate us to allow your ip full access, Email: sshnevis@outlook.com

ESAIC/ESRA guidelines for management related to anticoagulation for high bleeding risk blocks (neuraxial and deep nerve blocks)

Drug and dose	High risk of bleeding block (neuraxial and deep nerve blocks)
Drug and dose	Time from last drug intake to intervention	Target laboratory value at intervention	Time from intervention to next drug dose
VKA	Until target laboratory value: (about 3 days acenocoumarol; 5 days warfarin, fluindione; 7 days phenprocoumon)	INR normal
DXA low*	24 hours rivaroxaban, edoxaban (30 hours if CrCl <30 mL/minute), 36 hours apixaban	No testing
DXA high	72 hours or until target laboratory value (until target laboratory value if CrCl <30 mL/minute)	DXA level <30 ng/mL (alternative: ≤0.1 anti-Xa international units/mL)	Low doses: according to guidelines on postoperative VTE prophylaxis^¶ (about 8 hours − t_max = 6 hours postoperative). Consider prolonged time interval after bloody tap.^Δ
Dabigatran low*	48 hours	No testing
Dabigatran high	72 hours or until target laboratory value (until target laboratory value if CrCl <50 mL/minute)	DTI level <30 ng/mL (alternative: thrombin time in normal range of local laboratory)	High doses: according to guidelines on therapeutic anticoagulation^◊ (about 24 hours postoperative).
LMWH low ≤50 anti-Xa international units/kg/day Enoxaparin ≤40 mg/day	12 hours (24 hours if CrCl <30 mL/minute)	No testing
LMWH high	24 hours (48 hours if CrCl <30 mL/minute) or until target laboratory value (especially if CrCl <30 mL/minute)	≤0.1 anti-Xa international units/mL	VKA, DOAC, LMWH high, UFH high; should not be administered with a catheter in situ.
UFH low ≤200 international units/kg/day SC ≤100 international units/kg/day IV	4 hours	No testing	UFH low: 1 hour for IV in cardiovascular surgery.
UFH high	Until target laboratory value (about 6 hours if IV, 12 hours if SC)	aPTT or anti-Xa or ACT in normal range of local laboratory
Fondaparinux low ≤2.5 mg/day	36 hours (72 hours if CrCl <50 mL/minute)	No testing
Fondaparinux high	Until target laboratory value (about 4 days)	Calibrated ≤0.1 anti-Xa international units/mL
Aspirin low ≤200 mg/day	0	No testing	Routinely prescribed next time point.
Aspirin high	3 days (in normal platelet counts) to 7 days	(Consider specific platelet function tests in normal range of local laboratory)	6 hours.
P2Y₁₂ inhibitor	5 days ticagrelor; 5 to 7 days clopidogrel; 7 days prasugrel; or until target laboratory value		0-hours clopidogrel 75 mg; 24 hours prasugrel, ticagrelor; 2 days clopidogrel 300 mg.
Aspirin low + anticoagulant	Aspirin: 0 + time interval of specific anticoagulant	Specific laboratory test for combined anticoagulant	Aspirin low: routinely prescribed next time point. Combined anticoagulant, antiplatelet drug: according to guidelines on therapeutic anticoagulation, platelet inhibition^◊ (about 24 hours postoperative).
Aspirin low + antiplatelet drug	Aspirin: 0 + time interval of specific antiplatelet drug	(Consider specific laboratory test for combined antiplatelet drug)

ESAIC: European Society of Anaesthesiology and Intensive Care; ESRA: European Society of Regional Anaesthesia; VKA: vitamin K agonist; INR: international normalized ratio; DXA: direct Xa agonist; CrCl: creatinine clearance; VTE: venous thromboembolism; DTI: direct thrombin inhibitor; LMWH: low molecular weight heparin; DOAC: direct-acting oral anticoagulants; UFH: unfractionated heparin; IV: intravenous; SC: subcutaneous; aPTT: activated partial thromboplastin time; ACT: activated clotting time; EHRA: European Heart Rhythm Association.

* Definitions of low and high DOAC doses:

Rivaroxaban – Low dose is defined as 2.5 mg twice daily or 10 mg once daily; high dose as 15 mg twice daily or 20 mg once daily when used for VTE treatment or atrial fibrillation. When used for extended thromboprophylaxis, 20 mg once daily is considered low dose.
Apixaban – Low dose is defined as 2.5 mg twice daily (as long as certain criteria are absent, such as age ≥80 years, body weight <60 kg, or chronic kidney impairment), and high dose as 5 or 10 mg twice daily.
Dabigatran – Low dose is defined as 220 mg once daily, or 150 mg once daily if CrCl is 30 to 50 mL/minute or age ≥75); high dose is defined as 150 mg twice daily, or 110 or 150 mg twice daily if CrCl is <50 mL/minute or age 75 to 80, or 110 mg twice daily if age ≥80.

¶ For example, ESAIC guidelines on VTE prophylaxis.^[1,2]

Δ Blood in the needle/catheter.

◊ For example, EHRA guidelines.^[3]

References:

Afshari A, Ageno W, Ahmed A, et al. European Guidelines on perioperative venous thromboembolism prophylaxis: executive summary. Eur J Anaesthesiol 2018; 35:77.
Samama CM, Afshari A. European guidelines on perioperative venous thromboembolism prophylaxis. Eur J Anaesthesiol 2018; 35:73.
Steffel J, Verhamme P, Potpara TS, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of nonvitamin K antagonist oral anticoagulants in patients with atrial fibrillation: executive summary. EP Europace 2018; 20:1231.

From: Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100. DOI: 10.1097/EJA.0000000000001600. Copyright © 2022 European Society of Anaesthesiology and Intensive Care. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.

Graphic 138528 Version 1.0