Manejo de antiagregantes y anticoagulantes en procedimientos intervencionistas de dolor crónico

摘要

Interventional pain physicians usually face situations were, the patients that are going to be under an interventional procedure, are undergoing an antiplatelet or anticoagulant therapy. Bleeding complications can be catastrophic when we talk about deep blocks and interventions into the spinal canal. However, the risk of thromboembolic events increases with the improper discontinuation of antiplatelet and anticoagulant drugs in those patients. Nowadays, there are no algorithms or updated recommendations on the handling of those patients in the chronic pain area. The goal of this article is to offer some recommendations on how to use, in a safety way, those drugs depending on the type of intervention and patient, with the objective of minimizing the risk of bleeding complications without increasing the risk of thromboembolic events. To do this, the latest news on the use of drugs which alters the hemostasis in regional anesthesia and other chronic pain technics had been reviewed, including different guides on the perioperative management (ASRA, ESA, SEDAR, etc.). There is fair evidence that the risk of thromboembolic phenomenon increases on those patients whom discontinues their antiplatelet therapy, and that this risk is even higher than the risk of epidural hematomas on those patients whom continues with their treatment, even though both risks are significant. There is also good evidence of the incidence of spontaneous epidural hematomas, associated or not to a traumatic puncture, in patients with or without an antithrombotic therapy. Those spontaneous epidural hematomas are more likely associated to favorable factors such as: Excessive manipulation, the use of larger gauge needles, the use of catheters, procedures into the cervical spinal canal, elderly patients, and vascular and anatomical abnormalities of the patient. There is a less conservative tendency about intervals of discontinuation of antiplatelet drugs in high risk patients (3 days for Aspirin?, 5 days for clopidogrel), while the use of heparin and classic oral anticoagulants practically has not changed. Recently, new oral anticoagulants, not included in most of these guides, have appeared (dabigatran, rivaroxaban and apixaban) with a higher security profile than Sintrom?, usually without the need of heparin bridging therapy after discontinuation of the drug. The inconvenience is that there is limited evidence about its perioperative use. That is why it's suspension is actually based on its strict pharmacokinetic and pharmacodynamics characteristics (2 days, being higher if there exists a decline in renal function).