ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 1 مورد

SOAP consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants

SOAP consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants
SOAP (2017) Intrapartum Postpartum
Elective Urgent and emergent
SUBQ UFH For low-dose UFH thromboprophylaxis (ie, 5000 units SUBQ twice daily or three times daily):
  • Consider holding dose for 4 to 6 hours before NB or assessing coagulation status (Class IIa C-EO)

For intermediate-dose UFH thromboprophylaxis (eg, 7500 units SUBQ twice daily or 10,000 units SUBQ twice daily):

  • Consider holding dose 12 hours and assessing coagulation status before NB (Class IIa C-EO)

For high-dose UFH (eg, individual dose >10,000 units SUBQ per dose, or >20,000 units SUBQ total daily dose):

  • Consider holding dose 24 hours before NB and assessing coagulation status (Class IIa C-EO)
 For low-dose UFH thromboprophylaxis (ie, 5000 units SUBQ, twice daily or three times daily):
  • ASRA suggests waiting 4 to 6 hours after last dose before NB or assessing coagulation status
    • However, in urgent cases, with greater competing risks of GA compared to the risk of SEH from neuraxial procedure, the placement of neuraxial anesthesia without delay may be appropriate (Class IIa C-EO)

For intermediate-dose UFH thromboprophylaxis (eg, 7500 units SUBQ twice daily or 10,000 units SUBQ twice daily):

  • ASRA suggests waiting 12 hours after last dose before NB and assessing coagulation status
    • However, in urgent cases, with greater competing risks of GA compared to the risk of SEH from neuraxial procedure, the placement of neuraxial anesthesia without delay may be appropriate (Class IIa C-EO)

For high-dose UFH (eg, individual dose >10,000 units SUBQ per dose or >20,000 units SUBQ total daily dose):

  • If ≥ 24 hours since dose and normal coagulation assessment (eg, aPTT within normal range or undetectable antifactor Xa level), likely low risk to proceed with NB. Otherwise, insufficient additional data to recommend proceeding with NB (Class IIb C-EO)
 For SUBQ UFH thromboprophylaxis (ie, regardless of dose):
  • Wait ≥1 hour after NB and after CR before initiating or restarting UFH
  • Indwelling catheters can be maintained with low dose (specifically UFH 5000 units SUBQ twice daily)
    • CR can occur ≥4 to 6 hours after a dose of UFH and subsequent UFH dosing should occur ≥1 hour after CR (Class IIb C-EO)
  • Consider holding NSAIDs (including aspirin), but not acetaminophen, until CR if receiving thromboprophylaxis (Class IIa C-EO)
Intravenous UFH
  • Consider stopping infusion 4 to 6 hours and then assessing coagulation status before placing NB (Class IIa C-EO)
  
  • Wait ≥1 hour after NB before initiating or restarting anticoagulation (Class IIb C-EO)
LMWH For low-dose LMWH thromboprophylaxis (eg, enoxaparin ≤40 mg SUBQ once daily or 30 mg SUBQ twice daily, or dalteparin 5000 units SUBQ once daily):
  • Consider holding dose ≥12 hours before placing NB (Class I C-EO)

For intermediate-dose LMWH thromboprophylaxis (eg, enoxaparin >40 mg SUBQ once daily or 30 mg SUBQ twice daily and <1 mg/kg SUBQ twice daily or 1.5 mg/kg SUBQ once daily or dalteparin >5000 units SUBQ once daily and <120 units/kg SUBQ twice daily or 200 units/kg SUBQ once daily):

  • Insufficient data to recommend specific interval between 12 and 24 hours to delay before NB (Class IIb C-EO)

For higher dose LMWH (eg, enoxaparin 1 mg/kg SUBQ twice daily or 1.5 mg/kg SUBQ once daily; dalteparin: 120 units/kg SUBQ twice daily or 200 units/kg SUBQ once daily):

  • Consider holding dose ≥24 hours before placing NB (Class I C-EO)
 For low-dose LMWH thromboprophylaxis (eg, enoxaparin ≤40 mg SUBQ once daily or 30 mg SUBQ twice daily; or dalteparin 5000 units SUBQ once daily):
  • If given ≥12 hours ago, likely low risk to proceed with NB (Class I C-EO)
  • If given <12 hours before planned NB: insufficient additional data to recommend proceeding with NB
    • However, in high-risk circumstances where urgent intervention is needed for maternal or fetal indications, risk of GA may be higher than the risk of SEH with NB (Class IIb C-EO)

For intermediate-dose LMWH thromboprophylaxis (eg, enoxaparin >40 mg SUBQ once daily or 30 mg SUBQ twice daily and <1 mg/kg SUBQ twice daily or 1.5 mg/kg SUBQ once daily or dalteparin >5000 units SUBQ once daily and <120 units/kg SUBQ twice daily or 200 units/kg SUBQ once daily):

  • Insufficient data to recommend specific interval between 12 and 24 hours to delay before NB (Class IIb C-EO)

For higher dose LMWH (eg, enoxaparin 1 mg/kg SUBQ twice daily or 1.5 mg/kg SUBQ once daily; dalteparin: 120 units/kg SUBQ twice daily or 200 units/kg SUBQ once daily):

  • If given ≥24 hours, likely low risk to proceed with NB (Class I C-EO)
  • If given <24 hours, insufficient additional data to recommend proceeding with NB (Class IIb C-EO)
 For low-dose LMWH thromboprophylaxis (eg, enoxaparin <40 mg SUBQ once daily or 30 mg SUBQ twice daily; or dalteparin 5000 units SUBQ once daily):
  • Wait ≥12 hours after NB and ≥4 hours after CR before initiating or restarting LMWH thromboprophylaxis
  • Indwelling catheters can be maintained with low-dose LMWH:
    • CR can occur ≥12 hours after a LMWH dose and subsequent LMWH dosing should occur ≥4 hours after CR (Class I C-EO)
  • Consider holding NSAIDs (including aspirin), but not acetaminophen, until CR if receiving thromboprophylaxis (Class IIa C-EO)

For higher dose LMWH (eg, enoxaparin 1 mg/kg SUBQ twice daily or 1.5 mg/kg SUBQ once daily; dalteparin: 120 units/kg SUBQ twice daily or 200 units/kg SUBQ once daily):

  • Consider waiting ≥24 hours after NB and ≥4 hours after CR before initiating or restarting LMWH thromboprophylaxis (Class I C-EO)
This SOAP consensus statement is not intended to set out a legal standard of care and does not replace medical care or the judgment of the responsible medical professional considering all the circumstances presented by an individual patient. This consensus statement is not intended to ensure a successful patient outcome in every situation and is not a guarantee of any specific outcome. This consensus statement is subject to periodic revision as additional data becomes available. These recommendations assume normal renal function in the context of pregnancy, body weight >40 kg, and no other contraindications to neuraxial anesthesia.
aPTT: activated partial thromboplastin time; ASRA: American Society of Regional Anesthesiology and Pain Medicine; Class is based on American Heart Association system (1 strong, 2a moderate, 2b weak); C-EO: Consensus of expert opinion based on clinical experience; CR: catheter removal; GA: general anesthesia; LMWH: low molecular weight heparin; NB: neuraxial block; NSAID: nonsteroidal anti-inflammatory drug; SEH: spinal epidural hematoma; SOAP: Society for Obstetric Anesthesia and Perinatology; SUBQ: subcutaneous; UFH: unfractionated heparin.
Reproduced with permission from Wolters Kluwer Health, Inc.: Leffert L, Butwick A, Carvalho B, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants. Anesth Analg 2018; 126(3):928-944. Copyright © 2017 International Anesthesia Research Society. https://journals.lww.com/anesthesia-analgesia/pages/default.aspx.
Graphic 145646 Version 2.0