ASRA Guidelines

Question 1

What do the ASRA guidelines say about NSAID use prior to neuraxial anesthesia?

Answer 1

No contraindication to RA with concurrent NSAID use.

Question 2

What do the ASRA guidelines say about plavix use prior to neuraxial anesthesia?

Answer 2

Discontinued 7 days prior to neuraxial anesthesia.

Question 3

What do the ASRA guidelines say about Ticlid (ticlopidine) use prior to neuraxial anesthesia?

Answer 3

Discontinue 14 days prior

Question 4

Mechanism and class of ticlopidine and clopidegrel?

Answer 4

ADP-receptor inhibition and belong to the thienopyridine class

Question 5

What do the ASRA guidelines say about glycoprotein IIB/IIIa inhibitor use prior to neuraxial anesthesia?

Answer 5

Discontinue 8 - 48 hours prior depending on half life of the specific medication.

Question 6

Name three glycoprotein IIB/IIIa inhibitors.

Answer 6

Abciximab
Tirofiban
Eptifibatide
These are antiplatelet medications

Question 7

When are glycoprotein IIb/IIIa inhibitors typically used?

Answer 7

During interventional cardiology procedures.

Question 8

What do the ASRA guidelines say about subcutaneous heparin use prior to neuraxial anesthesia?

Answer 8

There is no contraindication to neuraxial anesthesia for subq heparin in twice daily dosing where total daily dose is > 10,000 units. More than this dose–>safety has not been established. Consider delay if the block is anticipated to be difficult.

Question 9

What do the ASRA guidelines say about IV heparin use and neuraxial anesthesia?

Answer 9

Wait at least an hour post-block to administer IV heparin. Wait 2 - 4 hours since last dose before pulling a catheter.

Question 10

What do the ASRA guidelines say about low-molecular weight heparin use and neuraxial anesthesia?

Answer 10

Twice daily dosing = wait 24 hours
Single daily (prophylactic) dosing = wait 10 - 12 hours
Wait 4 hours after placement of neuraxial anesthesia (with or without catheter) before administering another dose or pulling a catheter.

Question 11

What do the ASRA guidelines say about herbal supplements like garlic and neuraxial anesthesia?

Answer 11

No discontinuation recommended.

Question 12

What do the ASRA guidelines say about coumadin use and neuraxial anesthesia?

Answer 12

Wait for normalization of the INR before placing a catheter/performing spinal. If coumadin is started after epidural catheter placement, INR must be < 1.5 for catheter to be pulled.

Question 13

What class of drug is coumadin?

Answer 13

Vitamin K antagonist

Question 14

What are the vitamin k derived factors?

Answer 14

II, VII, IX, X, protein C, protein S

Question 15

What is fondaparinux?

Answer 15

A Factor Xa inhibitor like enoxaparin.

Question 16

What is the mechanism of enoxaparin?

Answer 16

Factor Xa inhibition

Question 17

How do the ASRA guidelines for fondaparinux differ from those of enoxaparin?

Answer 17

Fondaparinux may place the patient at greater risk for neuraxial bleeding. Thus, if fondaparinux is to be initiated after neuraxial anesthesia, it should be only in the case of a single, uncomplicated spinal injection. Difficult placement or catheterization should preclude its use. Avoid catheters.

Question 18

What do the ASRA guidelines say about fondaparinux use prior to neuraxial anesthesia.

Answer 18

Nothing. However, the European Guidelines recommend waiting 36 - 42 hours after the last dose.

Question 19

What drugs act by direct thrombin inhibition?

Answer 19

Argatroban
Dabigatran (a.k.a. pradaxa)
Bivalirudin
Desirudin
Lepirudin

Question 20

Hirudins are derived from where and are what class of drug?

Answer 20

Leeches

Anticoagulants via direct thrombin inhibition

Question 21

What do the ASRA guidelines say about direct thrombin inhibitor use and neuraxial anesthesia?

Answer 21

They state there is insufficient evidence and thus recommend avoidance of regional techniques.

Question 22

What class of drug is alteplase and how does it work?

Answer 22

Thrombolytic via plasminogen activation

Question 23

Name three plasminogen activators.

Answer 23

Alteplase
Reteplase
Tenectplase

Question 24

What do the ASRA guidelines say about plasminogen activors and neuraxial anesthesia?

Answer 24

Their use is an absolute contraindication to neuraxial anesthesia.

Question 25

What herbal supplements affect hemostasis and what is the duration of their effects?

Answer 25

Garlic - 7 days (platelet inhibitor, incr fibrinolysis, may be irreversible)
Ginko - 36 hours (inhibits platelet activating factor)
Ginseng - 24 hours (increases PT and aPTT in animals and counterintuitively, may decrease coumadin’s potency)

Question 26

How would you monitor argatroban’s effect?

Answer 26

PTT levels

Question 27

What is the management of anticoagulation in a pregnant woman approaching full term?

Answer 27

Prior to 36 weeks - oral regimen
After 36 weeks - enoxaparin
36 hours before IOL or c-section - switch to IV or subq heparin
4 hours prior to delivery - discontinue all anticoagulants

Question 28

When should anticoagulants be restarted in the parturient after delivery of the baby?

Answer 28

FOR RESTARTING PROPHYLACTIC DOSING
If after c-sxn –> wait for 24 hours
If after vaginal –> wait 12 hours after delivery or 12 hours after epidural removal, whichever is later.

FOR RESTARTING THERAPEUTIC DOSING
Wait for 24 hours regardless of mode of delivery

Question 29

What is thought to be the most likely injury from PNB in an anticoagulated patient?

Answer 29

Massive bleeding (whereas in a neuraxial block the more likely injury is neurologic devastation)

Question 30

Are the ASRA guidelines actually guidelines?

Answer 30

No. They’re not based evidence. By their own admission they’re a consensus statement.