Department of Anesthesia, Wayne State University/Detroit Medical Center, MI 48201, USA.
Br J Anaesth. 2010 Apr;104(4):429-32. doi: 10.1093/bja/aeq029. Epub 2010 Feb 23.
The administration of anti-platelet agents to surgical patients with a history of coronary artery disease or peripheral vascular disease represents an everyday challenge to anaesthesiologists when epidural anaesthesia or analgesia is to be considered. Practice guidelines suggest stopping clopidogrel at least 7 days before placing an epidural catheter. Withholding anti-platelet drugs represents a great risk to many of these patients. On the other hand, withholding perioperative epidural analgesia denies the patients its benefits including faster resolution of postoperative ileus, earlier ambulation, decreased risk of thromboembolism and vascular graft thrombosis, and decreased hospital stay. The charts of 306 vascular surgical patients who received epidural analgesia without withholding clopidogrel perioperatively were reviewed for the presence of any postoperative complications related to the continued intake of clopidogrel. No postoperative neurological complications resulting from the use of epidural analgesia were found in any of these patients. The point estimate (95% confidence limits) for the risk of epidural haematoma or other complications for this study is 0 (0-1)%. No neurological complications were found as a result of placing an epidural catheter in patients actively taking clopidogrel. Owing to the small sample size, we cannot recommend the liberal use of epidural analgesia with ongoing clopidogrel administration at this time. Further prospective studies, with larger sample size, are needed in order to substantiate our findings.
对于有冠心病或外周血管疾病病史的手术患者，如果要考虑硬膜外麻醉或镇痛，麻醉师在管理抗血小板药物时会面临挑战。实践指南建议在放置硬膜外导管之前至少停用氯吡格雷 7 天。然而，停止使用抗血小板药物会使许多患者面临巨大风险。另一方面，术中停止使用硬膜外镇痛会使患者无法受益，包括术后肠麻痹更快缓解、更早活动、血栓栓塞和血管移植物血栓形成风险降低以及住院时间缩短。回顾了 306 例接受硬膜外镇痛而不停止围手术期氯吡格雷的血管外科患者的图表，以评估继续使用氯吡格雷与任何术后并发症之间的关系。在这些患者中，没有发现任何因使用硬膜外镇痛而导致的术后神经并发症。该研究中硬膜外血肿或其他并发症的点估计（95%置信区间）为 0（0-1）%。在接受氯吡格雷治疗的患者中，放置硬膜外导管并未导致任何神经并发症。由于样本量较小，目前我们不能推荐在持续使用氯吡格雷的情况下自由使用硬膜外镇痛。需要进行更大样本量的前瞻性研究来证实我们的发现。
