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Year : 2017  |  Volume : 61  |  Issue : 5  |  Page : 448-449  

New anticoagulants and antiplatelet agents in perioperative period: Recommendations and controversies!

Department of Anesthesiology and Pain Management, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Web Publication9-May-2017

Correspondence Address:
Abhijit S Nair
Department of Anesthesiology and Pain Management, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad - - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_252_17

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How to cite this article:
Nair AS, Rayani BK. New anticoagulants and antiplatelet agents in perioperative period: Recommendations and controversies!. Indian J Anaesth 2017;61:448-9

How to cite this URL:
Nair AS, Rayani BK. New anticoagulants and antiplatelet agents in perioperative period: Recommendations and controversies!. Indian J Anaesth [serial online] 2017 [cited 2020 Jul 14];61:448-9. Available from:


There are number of guidelines published by several reputed regional anaesthesia societies worldwide regarding safe practice of regional anaesthesia for performing central neuraxial blockade in patients on anticoagulants. There is no dispute or controversy while performing regional anaesthesia when the patient is being treated with unfractionated heparin, low molecular weight heparin or oral Vitamin K antagonists (warfarin, acenocoumarol).[1] However, there is a lack of consensus among different societies when neuraxial block is contemplated in patients on new anticoagulants, for example, rivaroxaban, dabigatran, apixaban, fondaparinux for approved and off-label indications [Table 1].[2],[3],[4]
Table 1: New anticoagulants, antiplatelets and recommendations by international societies

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The duration of stopping of some anticoagulants before placing a neuraxial catheter and for removal of catheter is not uniform in the guidelines given by the American Society of Regional Anaesthesia (ASRA), European Society of Regional Anaesthesiology and The Association of Anaesthetists of Great Britain and Ireland. The timing of catheter insertion and removal is planned according to the plasma half-life and the elimination half-life of a drug. The half-lives of these anticoagulants tend to prolong further in renal impairment. ASRA does not recommend the use of central neuraxial block and catheter placement in a patient on fondaparinux prophylaxis or treatment.

The reason for knowing all the existing guidelines, in a nutshell, is to practice safe regional anaesthesia so as to have a minimal risk of haemorrhagic complications such as epidural and spinal haematomas which has catastrophic outcomes. The knowledge of the available guidelines is important from medico-legal point of view in a situation where the anaesthesiologist gets involved in a medico-legal case involving neurological complications after regional anaesthesia.

These guidelines should be considered as recommendations and consensus statements by the societies that represent the experience of renowned authorities and experts in field neuraxial anaesthesia and anticoagulation associated with international societies. In controversial situations, every anaesthesiologist should individualise the regional anaesthesia plan. Proper documentation, adequate post-operative monitoring, informed consent and prompt intervention in case of a complications should be the approach while dealing with the patients on anticoagulants. The clinician should be careful while performing peripheral nerve blocks, interventional spine and pain procedures on patients on above-mentioned drugs. Although ASRA has come out with consensus guidelines, the experts have suggested to make decisions based on half-life of drug, concomitant use of other drugs interfering with coagulation and risk versus benefit ratio.[5]

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There are no conflicts of interest.

   References Top

Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Perioperative management of antithrombotic therapy: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 2 Suppl:e326S-50S.  Back to cited text no. 1
Membership of the Working Party; Harrop-Griffiths W, Cook T, Gill H, Hill D, Ingram M, Makris M, et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013;68:966-72.  Back to cited text no. 2
Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. 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.  Back to cited text no. 3
Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM; European Scoeity of Anaesthesiology. Regional anaesthesia and antithrombotic agents: Recommendations of the European society of anaesthesiology. Eur J Anaesthesiol 2010;27:999-1015.  Back to cited text no. 4
Narouze S, Benzon HT, Provenzano DA, Buvanendran A, De Andres J, Deer TR, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: Guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015;40:182-212.  Back to cited text no. 5


  [Table 1]


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