In , that issue came to fruition with the publication of consensus guidelines clarifying preprocedural and postprocedural management of nine classes of medications. A framework for risk assessment and stratification was also created on the basis of procedural risks, relevant anatomy, and potential for severe neurological injury. Although the framework for evaluating periprocedural risk remained essentially unchanged, in April notable updates were released in several areas, including risk reclassification of some pain procedures, new recommendations for newer medications, recommendations for dietary supplements, and adjusted recommendations for heparin and fondaparinux. The update includes additional evidence supporting diligence in the management of novel oral anticoagulants NOACs before and after neuraxial interventions, recommendations for considering coagulation studies in patients with renal or hepatic disease, and recommendations for routine use of physical examination findings for signs or symptoms of coagulopathy. Other changes include reducing peripheral nerve stimulation PNS , PNS implantation, and device pocket revision to the low-risk category as well.
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Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures.
The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines.
The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. The latest evidence was sought through extensive database search strategies and the recommendations were evidence based when available and pharmacology driven otherwise. We could not provide strength and grading of these recommendations because there are not enough well-designed large studies concerning interventional pain procedures to support such grading.
Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations. This publication is intended as a living document to be updated periodically with consideration of new evidence.
Antiplatelet and Anticoagulant Guidelines for Interventional Pain Procedures Released
Evolving standards for the prevention of perioperative venous thromboembolism VTE and the introduction of increasingly potent antithrombotic medications have resulted in concerns regarding the heightened risk of neuraxial bleeding. Furthermore, societies and organizations seeking to address these concerns through guidelines in perioperative management have issued conflicting recommendations. Earlier guidelines did not specify a time interval between SC administration of UFH and neuraxial blockade. These recommendations are based on the pharmacology of SC U dose of UFH, which results in a significant anticoagulant effect that persists 4 to 6 hours after administration. There is no contraindication to maintaining neuraxial catheters in the presence of low-dose UFH.
Updates to the ASRA Guidelines for Interventional Pain Procedures
Advisories & guidelines
Asra Anticoagulation Guideline Apps