Pain Management Centers of America, Paducah, KY and Evansville, IN; Departments of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; LSU Health Science Center, New Orleans, LA.
Pain Management Centers of America, Evansville, IN; Indiana University School of Medicine, Evansville, IN; Department of Anesthesiology, University of Louisville, Louisville, KY, USA.
Pain Physician. 2024 Aug;27(S6):S1-S94.
The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures.
Review of the literature and development of guidelines based on best evidence synthesis.
To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications.
Development of consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest.
A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy.
The continued paucity of literature with discordant recommendations.
Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.
接受抗凝和抗血小板治疗的慢性疼痛患者进行介入技术的频率继续增加。了解继续进行慢性抗凝治疗、介入技术的必要性以及确定抗凝治疗的持续时间和停药或暂时停药的重要性，对于避免灾难性并发症至关重要，尤其是在进行脊柱内程序时。抗凝剂和抗血小板药物针对凝血系统，增加出血风险。然而，停止抗凝或抗血小板药物会使患者面临血栓形成的风险，这可能导致重大发病率和死亡率，特别是在患有冠状动脉或脑血管疾病的患者中。这些指南总结了目前的同行评审文献，并根据最佳证据综合制定了基于共识的指南，为接受抗凝和抗血小板治疗的患者在介入过程中的治疗提供指导。
文献回顾和基于最佳证据综合制定指南。
提供有关评估接受抗凝和/或抗血小板药物治疗的患者在介入技术期间出血和血栓形成风险的最新简明文献评估。
基于最佳证据综合制定共识指南，包括对介入性疼痛程序期间出血风险、实践模式以及抗凝和抗血小板治疗的围手术期管理的文献回顾。一个由多学科专家组成的小组制定了方法、基于最佳证据综合的风险分层以及抗凝和抗血小板治疗的管理。它还包括根据多种因素停止抗凝和抗血小板治疗的风险。通过从 1966 年到 2023 年的多个数据库搜索确定了多个出血风险、实践模式、血栓形成风险和抗凝及抗血小板治疗围手术期管理相关的数据来源。在共识声明和指南的制定过程中，我们使用了改良德尔菲技术，该技术已被描述为最小化与小组互动相关的偏倚。无主要利益冲突的小组成员对批准特定指南声明进行投票。每位小组成员都可以对指南声明的措辞进行编辑，并可以提出额外的限定性评论或意见，以实现指南在临床实践中的实施，从而达成共识并将其纳入最终指南。每项指南声明都需要至少 80%的无主要利益冲突的合格小组成员的同意。
共有 34 位作者参与了这些指南的制定。其中，29 位参与了投票过程。共制定了 20 项建议。总体而言，20 项中的 16 项获得了 100%的接受率。通过第二轮和第三轮投票，项目总数减少到 18 项。最终结果是 16 项（89%）获得了 100%的接受率。有 2 项声明（第 6 项和第 7 项）和 3 位作者的建议存在分歧。其余 2 项的接受率为 94%和 89%。不同意和不同意见来自 Byron J. Schneider, MD，他建议所有经椎间孔都归类为低风险，而 Sanjeeva Gupta, MD 希望所有经椎间孔都归类为中风险。第二个分歧是 Vivekanand A. Manocha, MD 建议颈椎和胸椎经椎间孔为高风险手术。因此，通过适当的文献复习，为接受抗凝和抗血小板治疗的患者制定了基于共识的围手术期管理声明。这些包括：估计血栓栓塞风险、估计出血风险以及确定重新开始抗凝或抗血小板治疗的时间。风险分层提供了将介入技术分类为低风险、中风险或中风险、高风险的方法。此外，在低风险和中风险类别中多次建议不停止抗凝或抗血小板治疗。
持续缺乏文献和不一致的建议。
基于对现有文献、已发表的临床指南和建议的回顾，一个多学科专家小组提出了在围手术期管理接受抗凝或抗血小板治疗的患者的介入技术的指南。这些指南提供了对风险分类、适当建议以及基于最佳现有证据的建议的全面评估。
