From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA).
Eur J Anaesthesiol. 2022 Feb 1;39(2):100-132. doi: 10.1097/EJA.0000000000001600.
Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia.
A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline.
Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%.
Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply.
In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
出血是椎管内和外周神经阻滞的潜在并发症。在使用抗血小板和抗凝药物的患者中，风险增加。欧洲麻醉学会和重症监护学会以及欧洲区域麻醉学会联合制定的本指南旨在提供一套基于证据的建议和意见，以降低与区域麻醉和镇痛实践相关的抗血栓药物诱导血肿形成的风险。
进行了系统的文献检索，检查了七种药物比较和十种类型的临床干预，结果是外周和神经血肿。使用推荐评估、制定和评估（GRADE）分级对纳入研究的方法学质量进行评估，并制定建议。采用 Delphi 法制定临床实践指南。
临床研究数量有限，质量也不高，证据的确定性评估为 GRADE C 级。制定了 40 项临床实践陈述。通过 Delphi 过程，在 57.5%的建议中达成了强烈共识（>90%的一致性），在 42.5%的建议中达成了共识（75%至 90%的一致性）。
在进行椎管内操作或具有较高出血风险（深部、不可压缩）的外周神经阻滞之前和之后，应针对抗血栓药物的给药时间制定具体的时间间隔。这些时间间隔根据抗凝药物的类型和剂量、肾功能以及是否发生创伤性穿刺而有所不同。药物测量可用于指导某些时间间隔，而特定的维生素 K 拮抗剂和达比加群逆转也可能影响这些时间间隔。超声引导、药物组合和出血风险评分不会改变时间间隔。在出血风险较低（浅表、可压缩）的外周神经阻滞中，这些时间间隔不适用。
在使用抗血小板或抗凝药物的患者中，医生必须考虑神经阻滞前后以及导管插入或取出过程中的出血风险。管理此类患者的医疗团队必须意识到风险，并具备检测和管理任何可能血肿的能力。
