ASRA + SOAP Comment on ASRA App, Guidelines on Subcutaneous Heparin - Anesthesiology News

TO THE EDITOR:

On behalf of the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the Society for Obstetric Anesthesia and Perinatology (SOAP), we would like to follow up on the article “Obstetric Guidelines Affect Heparin and Neuraxial Anesthesia Practice—ASRA app prompts some confusion,” which appeared in your October 2016 issue, to provide some context. The major points of the article are that the new ASRA guidelines regarding subcutaneous standard heparin will have a significant impact on the management of selected antepartum patients for whom it is now recommended that thromboprophylaxis be administered¹ (and that the ASRA recommendations were not adequately vetted), as well as the delay in the publication of these guidelines.

The draft document of ASRA’s Fourth Edition of “Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy” now recommends that following administration of 5,000 U of subcutaneous standard heparin, neuraxial block be delayed four (ideally six) hours. This recommendation is consistent with the management regimens based on drug pharmacology, such as those of the European Society of Anaesthesiology² and the American College of Chest Physicians.^3,4 The FDA used this methodology when it changed the labeling of low-molecular-weight heparins (LMWHs) to recommend that subsequent dosing of a LMWH be delayed for four hours—rather than two—after neuraxial catheter removal.⁵ The reporting of a single international management recommendation could allow for standardization and decreased confusion regarding interpretation and application.

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Importantly, additional pharmacologic data regarding differences in pharmacokinetics or pharmacodynamics in pregnant compared with nonpregnant patients are being considered, and the recommendations will be revised to accommodate relevant information going forward. We acknowledge that this revised recommendation comes at a time when more pregnant women will be receiving thromboprophylaxis (often at 5,000 U of subcutaneous standard heparin).

A reason for the delay in publication is the ongoing, yearlong collaboration between ASRA and SOAP, with the intent of presenting consensus statements that balance the benefits of neuraxial anesthesia—of which there are many in the parturient population—with the small, but unknown risk of the catastrophic complication of spinal hematoma. We are confident that consensus will be reached and the final product will be helpful and consistent in the management of these patients.

Sincerely,

Oscar A. de Leon-Casasola, MD
ASRA President

Brendan Carvalho, MD
SOAP President-Elect

Lisa R. Leffert, MD
SOAP/ASRA task force on VTE in pregnancy

Terese T. Horlocker, MD
SOAP/ASRA task force on VTE in pregnancy

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References

1. D’Alton ME, Friedman AM, Smiley RM, et al: National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. Anesth Analg. 2016;123:942-949.
2. Gogarten W, Vandermeulen E, Van Aken H, et al: Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesth. 2010;27:999-1015.
3. Bates SM, Greer IA, Middeldorp S, et al: VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e691S-736S.
4. Bates SM, Middeldorp S, Rodger M, et al: Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis. 2016;41:92-128.
5. FDA Drug Safety Communication. Updated recommendations to decrease risk of spinal column bleeding and paralysis in patients on low molecular weight heparins. November 6, 2013. http://ift.tt/2i6XCoj. Accessed November 1, 2016.

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