Guideline for the management of hip fractures, 2020. A guideline by the Association of Anaesthetists (Draft)

 

Griffiths R , Babu S, Dixon  et al. 

Consensus statement from working group – open for comment

Our discussion focused on Appendix S1 – suggested management of hip fracture patients taking antiplatelet of anticoagulant medication

• Statement from guidance:
  • Single antiplatelet agent (including clopidogrel) are not a contraindication to spinal anaesthesia, if this is the best option for an individual patient

We reviewed the literature regarding spinal anaesthetics and the complication of a vertebral canal haematoma (VCH)

• NAP3
  • Estimated 325,000 spinals done per year
  • 8 cases of VCH, 5 meeting inclusion criteria
    • All cases were as a result of epidural, none from spinal
    • Observed that 7/8 involved disorders of coagulation (including drugs)
  • American Society of Regional Anaesthesia estimate 1 in 220,000 patients undergoing spinals will develop VCH
    • Horlocker et al, 2018

The following papers were reviewed to assess the increased risk of VCH with blood thinning agents

• NAP3
• Case reports reviewed from 1904-1994: 42/61 cases had disorders of coagulation
  • Vandermeulen et al (1994)
• American verses European dosing of enoxaparin
  • 30mg BD – 1 in 40,000 risk with spinal
    • Schroeder (1998)
  • 40mg OD – 1 in 156,000 risk with spinal
    • Moen (2004)
  • Clopidogrel continued throughout epidural – 306 vascular patients
    • No complications
    • Osta (2010)

Conclusions:

• Epidural have higher rates of VCH than spinals
• Spinal related VCH are rare without anticoagulation (1 in 130,000 to 220,000)
• Risk is increased with antiplatelet/coagulation
  • Drug/situation dependant
• Balance of risk benefit essential, however if you have concern about a GA it is very possible that the risk of VCH is lower than this

Summary by Dr J Arthur. Journal Club Meeting 17th September 2020.

References:

• Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165–1177.
• Schroeder DR. Statistics: detecting a rare adverse drug reaction using spontaneous reports. Reg Anesth Pain Med 1998; 23:183 – 189.
• Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004; 101:950–959.
• Gogarten, Wiebke; Vandermeulen, Erik; Van Aken, Hugo; Kozek, Sibylle; Llau, Juan V; Samama, Charles M Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology, European Journal of Anaesthesiology: December 2010 – Volume 27 – Issue 12 – p 999-1015 doi: 10.1097/EJA.0b013e32833f6f6f
• Harrop‐Griffiths, W., Cook, T., Gill, H., Hill, D., Ingram, M., Makris, M., Malhotra, S., Nicholls, B., Popat, M., Swales, H. and Wood, P. (2013), Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia, 68: 966-972. doi:1111/anae.12359
• Cook T, Counsell D, Wildsmith J, Project OBOTRCOATNA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102:179 – 190.
• Horlocker et all, Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy, Reg Anesth Pain Med 2018;43: 263–309
• A. Osta, H. Akbary, S. F. Fuleihan, Epidural analgesia in vascular surgery patients actively taking clopidogrel, BJA: British Journal of Anaesthesia, Volume 104, Issue 4, April 2010, Pages 429–432