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Antithrombotic drugs and the risk of bloody punctures in regional anesthesia - a retrospective registry analysis
  1. Christine Kubulus1,
  2. Christine A Gürtesch1,
  3. Gudrun Wagenpfeil2,
  4. Daniel I Sessler3 and
  5. Thomas Volk1
  1. 1Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
  2. 2Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
  3. 3Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA; Senior Fellow, Population Health Research Institute, McMaster University, Ontario, Canada
  1. Correspondence to Dr Christine Kubulus, Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, 66421 Homburg, Germany; christine.kubulus{at}uks.eu

Abstract

Introduction The risk of bleeding during regional anesthesia implementation in patients on antithrombotic therapy remains poorly characterized. We; therefore, analyzed bloody tap rates and adjusted ORs comparing patients who take antithrombotic medications with those who do not.

Methods 65,814 qualifying regional anesthetics (2007–2019) from the Network for Safety in Regional Anesthesia and Acute Pain Therapy registry were included in a retrospective cohort analysis. Procedures in patients who took antithrombotic drugs were compared with procedures in patients who did not. The primary outcome was bloody puncture, defined as any kind of blood aspiration during placement. Secondarily, we considered timely discontinuation of thromboprophylaxis and the impact of various drug classes. As a sensitivity analysis, we used propensity matched groups.

Results Patients on antithrombotic therapy were more likely to have a bloody puncture during peripheral nerve block implementation (adjusted OR 1.60; 95% CI 1.33 to 1.93; p<0.001) irrespective of whether therapy was discontinued. In contrast, bloody neuraxial blocks were no more common in patients who took antithrombotic medications (adjusted OR 0.95; 95% CI 0.82 to 1.10; p=0.523) so long as they were paused per guideline. Across both peripheral and neuraxial blocks, concurrent use of more than one platelet and/or coagulation cascade inhibitor nearly doubled the odds (adjusted OR, 1.89; 95% CI 1.48 to 2.40; p<0.001).

Discussion Patients on antithrombotic therapy receiving peripheral blocks are at increased risk for bloody punctures irrespective of discontinuation practice. Patients having neuraxial blocks are not at increased risk so long as antithrombotics are stopped per guidelines. Patients who take combined medications are at especially high risk. Guidelines for discontinuing antithrombotic treatments for neuraxial anesthesia appear to be effective and should possibly be extended to high-risk peripheral blocks.

  • REGIONAL ANESTHESIA
  • Anticoagulants
  • Nerve Block

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.

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Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.

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Footnotes

  • Contributors CK and TV contributed to planning, designing, and conducting the study, data analysis, drafting, revising, and submitting the manuscript. CK and TV act as guarantor. CAG and GW contributed to conducting the study, data analysis, interpretation and revising the manuscript. DIS contributed to the data analysis, drafting, and revising the manuscript.

  • Funding Support for the study was provided solely from institutional/hospital/departmental sources. The Network for Safety in Regional Anesthesia and Acute Pain Therapy is supported by the Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (N/A) and Berufsverband Deutscher Anästhesisten e.V. (N/A)

  • Competing interests DIS is a consultant for Pacira and his department conducts funded research for the company. Thomas Volk received honoraria for lectures from CSL Behring and Pajunk. CK, CAG and GW declare no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.