Anesthesia and Blood Thinners: New guidelines from ASRA Pain Medicine

What: New guidelines will be published by ASRA Pain Medicine on January 29, 2025 about the management of anesthesia in patients taking blood thinners and thrombolytics.

Who: Sandy Kopp, Mayo Clinic

When: Tuesday, January 28th at 2 PM ET

Where: Newswise Live Zoom Room (address will be included in follow-up email)

Media Register to Attend 

Transcript

Moderator: Hello and welcome to this Newswise Live Virtual press briefing. I’m here with representatives from the American Society of Regional Anesthesia and Pain Medicine to talk about new guidance being issued about the use of anesthesia in patients on blood thinners and other related types of medications. I’d like to first introduce Dr. Sandy Kopp at Mayo Clinic to talk a little bit about the guidance and give us an overview of things. Dr. Kopp, if you introduce yourself and tell us your kind of role and everything with ASRA and at Mayo Clinic, and tell us an introduction to this new guidance.

Dr. Kopp: I’m Sandy Kopp, I work at Mayo Clinic in Rochester, Minnesota, as well as our Mayo Clinic Health System. I’ve been there for about 25 years. I had the pleasure of working with Dr. Terry Horlocker, who is the person who essentially started these guidelines back in 1998, she was my mentor. I’ve been part of this guideline team for the last three editions, and when Dr. Horlocker retired, I took over as the lead author of this, which is a real privilege to me. I’ve been a member of the American Society of Regional Anesthesia since I was a resident, and I am now the treasurer and soon-to-be President-Elect in the Spring this year. So I am very involved in ASRA. These guidelines are close to my heart. I’ve been working on them for over 15 years as a Regional Anesthesiologist, which means that I do regional anesthesia for patients, is in addition to general anesthesia, which regional anesthesia is using things like spinal anesthesia, epidurals, peripheral nerve blocks, facial plane blocks, so essentially using local anesthetic to numb a portion of somebody’s body so that they don’t have to go all the way off to sleep under a general anesthetic. I’ve been doing this. I did a fellowship in this about 20 some years ago. And so as somebody who uses a lot of needles on people, it’s very important to make sure that their blood isn’t too thin. And so that’s what, where what these guidelines are developed, with the number of blood thinning medicines increasing dramatically since the first guideline in 1998 doing an every about five to seven year update has been really important, because there’s a lot of things that are added that we need to consider, to help keep our patients safe.

Moderator: To help understand a little bit of the context and impact of this, the types of procedures that you’re referring to, and the patients on the types of medications that you’re referring to. How much has that increased in recent years and since the most recent update to the guidance?

Dr. Kopp: Sure. So what we know is that there’s about 6 million Americans or so that are on the direct oral anticoagulants, which are kind of the newest blood thinning medicines. We also know that there’s about another 36 million or so that are on antiplatelet medications. So if you take just that 40 million patients in the United States, and you realize that about 20% of that 40 million will have a surgical procedure in a year. That’s a huge number of patients that are impacted by this. We know that there’s been a lot of research being done looking at the benefits of regional anesthesia, so spinal anesthesia, peripheral nerve blocks, helping postoperative pain control, decreasing opioids. So these techniques have become much more popular and have been proven to be quite beneficial. So this impacts a large number of people.

Moderator: And tell us about the more specifics of these procedures, the regional anesthesia and the potential risks related such as you told me earlier on, neuraxial hematoma as one of the possible problems. Tell us a little bit about some of the nitty-gritty of what those kinds of things involve.

Dr. Kopp: Sure. So for patients on blood thinning medicines. Who have surgery, you know, the first thing people think about is that they would have excessive bleeding, right, which might lead to a hemorrhage, might lead to requiring a blood transfusion. And those are all things that can still happen. What we’re worried about though, those of us who do regional anesthesia and who use neuraxial blocks, which are spinals or epidurals. What we’re worried about is the bleeding into the very tight, essentially neuraxis, which is the area around the spinal cord. That area is non it’s non, it doesn’t expand, so any degree of bleeding in that area can cause catastrophic outcomes for these patients. Essentially, the thing we worry the most about is a hematoma in that area or a blood clot that would then compress the spinal cord and can lead to paralysis in these patients. In patients undergoing peripheral nerve blocks, which is essentially numbing a specific nerve or a group of nerves, like, for example, if you were going to have surgery on your arm, we could do a nerve block somewhere up here. There’s a lot of areas, a lot of places to do it, but we can numb those nerves to the arm and essentially allow you to undergo that procedure without a general anesthetic, by just having a numb arm by putting a needle near those nerves. It’s a compressor, it’s a site that can expand a bit, but any significant bleeding to that area can cause ischemia to those nerves and can injure the nerves that we’re blocking.

Moderator: So Dr. Kopp, you mentioned an epidural that also, I think, probably reminds a lot of listeners to of women in labor and giving birth. So I’d like to bring in Dr. Lisa Leffert to talk more specifically about that. Dr. Leffert, if you could introduce yourself and your position where you work, and tell us a little bit about how this applies to pregnant women in labor and delivery, getting an epidural?

Dr. Leffert: Absolutely, a pleasure to see everyone. So I’m Lisa Leffert. I’m the chair of anesthesiology at Yale. I’m also an obstetric anesthesiologist and have worked in this field for about 30 years, and I have learned just how important pain management is through my own experiences and my patients’ experiences are when you are having a baby, if you’re looking at ways in which to manage pain, labor pain, and you’re looking specifically at what does the best job at managing the pain. These kinds of anesthetics that we’re talking about, spinals and epidurals probably do the best job. And then if you need a C-section. That’s a whole discussion in and of itself. But certainly being able to have the C-section, having the option to have the C-section with a spinal or an epidural rather than general anesthesia, has a lot of advantages as well. So what do you do when you have patients who need these blood thinning medications, but also need these forms of anesthesia or pain management? And the answer is, you weigh the pluses and the minuses. So the fundamental things that Dr. Kopp was talking about, are the same. One thing that I will say is that if you’re going to be someone in this position, being a pregnant woman is a very good person to be, and that’s for a few reasons. Pregnant women mostly are very healthy. Their blood clots very well. That’s a native thing we have because everyone knows that there’s some bleeding with childbirth, so we are born to clot well when we’re pregnant and delivering a baby, and also that tight space that we were talking about around the spinal cord is as loose and the word compliant comes to mind as it’s gonna be in a young person, in most cases unless there’s other things going on. So that is really good if you were to get a hematoma, about the chances of it pushing on the nerves. All that said, we still need to worry about these things. So, there’s a lot of planning that goes into using the medications which are needed in pregnant women, in part because of the fact that they are clotters and when they start to go into labor, when they come in to deliver. And I have to say, it has been extremely wonderful to work with the ASRA group as an obstetric anesthesia group representative in bringing it all together for patients and their physicians.

Moderator: Thank you, Dr. Leffert. Dr. Kopp, tell us a little bit more about the types of risks involved for these kinds of patients. If someone’s on blood thinners or other similar related medications, they may have, clearly, some other health issues going on. How does that complicate things when evaluating and approaching how to accomplish this sort of anesthesia that’s necessary for whatever procedure they’re about to undergo?

Dr. Kopp: Yeah, that’s a very good question. So the majority of the time, we’re using these procedures in orthopedics, and a lot of these patients are patients who have arthritis and are undergoing hip or knee replacement. We do a lot of those under spinal anesthesia because they have arthritis in their hips and their knees, they probably have arthritis in their spine, which essentially can lead to spinal stenosis, which is a tightening or a narrowing of that already noncompressible, tight area. So patients who are undergoing these procedures that typically have a spinal are probably going to be at the highest risk. We know that the risk, it’s really difficult to know exactly what the risk is, and it’s really hard to study because it’s so incredibly rare. But what we know is that approximately about 1 in 150,000 epidurals can lead to neuraxial hematoma and about 1 in 220,000 spinals. So the risk is smaller with a spinal because the needle is much smaller. That being said, probably the best study for this was done in Sweden and in 2004 by Doctor Mohan. And the highest risk group was the elderly women undergoing total knee replacement under epidural. And their risk was as high as about 1 in 3,600 which is obviously much different than the 1 in hundreds of thousands that I told you about if you have no other risk factors. So the risk factors we’re concerned about are patients who are typically elderly, specifically females, those who have kidney or liver problems, because it can lead to not metabolizing the blood thinning medicine, or the half-life of it lasts longer, which means the effect of it lasts longer for those patients. Other risk factors are obviously patients who are on these blood thinning medicines, and whether it’s a difficult needle placement or not, which obviously, in patients who have a lot of arthritis in their back, it can be very difficult to place this needle. So those are the types of things that we worry about. And you know, from what I just said, you can hear that a lot of the risks, if you look at the patients who are at risk, it’s the patients who were oftentimes doing these procedures on.

Moderator: I’d like to introduce Dr. Gupta and ask a little bit about the practitioners, the surgeons, the physicians, the anesthesiologists, that you are hoping to reach with this guidance. And you worked on creating an app version with these resources, so if you could introduce yourself, where you’re from, your position there, and tell us a little bit about creating that media, that smartphone-based, access to this for those clinicians.

Dr. Gupta: Thank you, Thom. My name is Raj Gupta. I’m a professor of anesthesiology at Vanderbilt University in Nashville, Tennessee. I’m also a member of the Board of Directors for the American Society of Regional Anesthesia and Pain Medicine. I’ve been involved with ASRA Pain Medicine since about 2007 in some capacity or another, and it has really been a privilege to be part of this community and part of this project that affects most anesthesiologists in some way or another. One of the questions that I came to when I was first interested in the project, of creating an app or these guidelines, was solving a problem I had at my own institution, as you heard during this conversation. This is complicated stuff, and it’s important. It’s important because the procedures are important for patients, but it’s also important not to cause them harm in the process of doing those procedures. And so we have this intersection of a very complex situation, good information, but it’s only useful if the right information is in the hands of the doctors, the surgeons, the anesthesiologists, and the people taking care of these patients. So part of the solution was because we were facing the problem at our own institution, and we developed this app and did it in collaboration with ASRA, so that it was consistent with the evidence-based guidelines that were being published, and we did the first version in 2014 as part of the third edition of these guidelines and realized that we really had a hit on our hands, because people said saw the same problem we did, which is they needed that information, but in an easy to use way, the guidelines because they have so much detail in them, can often be 70, 80, 90 pages long, and it’s hard to consume that information in the moment. It’s definitely hard to memorize it. And so what we did is, my goal was in the app is, I want people to be able to get to the right answer within 3 to 4 clicks, and then I also wanted a tool that could be adapted with new information over time. So as new drugs came out, new science came out, we could adapt and update the software in the back end, and now people had the new information without really having to change their behavior. In 10 years, we have seen this go global. So, people, the guidelines are important to people all over the world. Well, the app is there, one of the most common ways people access that information. And we’ve had over, I think, you know, an install base of 200 to 250,000 worldwide, and it, and I hear regularly from people that they use this almost every clinical day. This is not something they access once, learn something and put it away. Even the developer we worked with was astonished that 10 years later, people are still downloading this app because he said he’s never had that kind of happen with anything else that he’s developed. There’s very few apps on this app store that you see that people are still into many, many years later. And so we have a new one coming out. I don’t know if you want to get to that right now, but we have a new update to the app coming out very soon to go along with this fifth edition of these guidelines.

Moderator: Great. Thank you, Dr. Gupta. Dr. Kopp, we have a question from a member of the media, Lynn, from Trends in Medicine, what is new about the guidelines?

Dr. Kopp: Hi, Lynn, thank you. So yeah, there’s a few things that are new. For one, it’s just really good to review all of these medications, to review all of the case reports of potential problems every about five to seven years, to make sure that we’re not missing something. What’s new in these guidelines is that we’ve changed our wording we used to use essentially therapeutic and prophylactic as far as the dosing goes, and we’ve changed that now to low and high dose, which actually allows us to be more consistent with the European guidelines. We don’t, it’s not helpful to anybody when you have differing guidelines about the same topic. So we worked, one of our co-authors, Dr. Van Der Meulen, is also on the European guidelines. And so that allows us to speak in the same language. What we do know is that, depending on what this medication is used for and what the patient’s comorbidities are, sometimes the same dose can be therapeutic or prophylactic. But so that’s why we’re now using the terms low and high dose, because that is a little bit more defined. The other thing, as the blood test to determine whether a patient remains anti-coagulated after they’ve been off these medications. There’s blood tests to help with that, and those have not been very easy to access in a lot of institutions, they’re becoming more easy to access. And so we put recommendations for what we would recommend, as far as what the blood test should show and maybe which patients you should actually draw the blood test on. Not every patient needs a blood test if they follow the recommendations. There are a few other kinds of very specific, like to a specific drug recommendation change, but primarily it’s just really reviewing these medications, reviewing the case reports to make sure that we’re providing people with the most up-to-date recommendations.

Moderator: And tell us about the app and what it’s called and where people can find it, or where they will be able to find it.

Dr. Gupta: Yeah, thank you. So the app is called “ASRA Coags”, so ASRA, and then the name is C, O, A, G, S, there’s a version currently in the Apple iOS App Store and the Google Play Store, but the new version we’re going to be publishing to go along with these guidelines is coming out in a couple of weeks. We’re doing some last bit of bug fixes and content clarification, but it will stand alone from the existing so the existing app will go away. We’re doing a whole new code based on it, so it’s not just an update to the original one, it’s actually a brand new code base on the back end, it’s difficult to keep up with all the operating system updates that these phone manufacturers do, so sometimes we have to kind of start from scratch and rewrite the baseline code, but it will still can carry the same name ASRA Coags, and will come out in a couple weeks.

Moderator: That name coags referring to the anticoagulant medicines. Yeah, got it understood.

Dr. Gupta: It’s the shorthand that a lot of us doctors use for talking about this topic, so it felt appropriate.

Moderator: Sounds right. COAGS, learn something new. And Dr. Kopp, these new guidelines, will be published in the ASRA journal. Is that correct? And when will that be? 

Dr. Kopp: Yeah, Regional Anesthesia and Pain Medicine is our journal, RAPM. We call it RAPM, and they are going to be published on January 29th, I believe.

Moderator: Excellent, for members of the media. If you’re interested in seeing this paper and asking any follow-up questions, I’ve chatted Elizabeth Smith, the communications person at ASRA pain medicine, her email address, so that you can contact her and receive a copy of that. And we ask, of course, that you keep any information confidential until the time that that’s published tomorrow, on the 29th, and then the embargo is lifted and you’re able to publish about this. Dr Kopp, is there anything else that you’d like to share and make sure that media understand about this, so that their readers and and patients out there in the public, and especially, of course, other anesthesiologists and surgeons and other people in medicine find out about this and learn about it and get access to anything else you’d like to share, so that they understand.

Dr. Kopp: Yeah, no, I think you know what you said about other surgeons. I think that is really an important piece. Because remember, we’re recommending when these medications need to be stopped. As an anesthesiologist, I don’t usually get to see my patient until the morning of surgery, so it’s kind of too late then. So it is really important that we target the surgeons, the primary care providers so that they understand what our recommendations are and can stop these medications in the appropriate time before they get to us. So I think that is key. Otherwise, no, I think you know this. This is because we know that regional anesthesia is a benefit to a lot of patients, and these guidelines will help keep those patients safe.

Moderator: Thank you, Dr. Kopp. It certainly sounds like with the increase of these types of procedures and the prevalence of these types of prescription medications, that this is very important to continue to update these guidelines as it affects more and more people. One other question from the chat, Lynn at Trends in Medicine, asks, “Do you have a message for patients on the use of DOACs”?

Dr. Kopp: That’s a very good question. I guess what I would counsel patients, is that if they’re going to have a surgical procedure, to talk to their primary care provider or their surgeon and ask them, ‘What are the recommendations for stopping these medications? I think it’s really important for patients to be proactive and not just assume that their primary care or their surgeon is going to realize that they’re on these or tell them when to stop. So if you know, I think that would be the best message, if they know they’re on these medications and they’re coming for surgery, to just ask.

Moderator: Great advice, certainly not something that you want to be missed and you hope that it’s reviewed as going through your chart, but a patient can always benefit by making sure to raise that question and bring it up to their physician and their anesthesiologist. Great. Well, another question here, oh, that’s just a comment from is there? Okay, so let me just read this question here. Sorry. Is there anything that she has written? Okay, another question from Ajai, is there anything that anesthesiologists in particular should know, anything they can do in addition to communicating with surgeons and PCPs?

Dr. Kopp: You know, I think as long as anesthesiologists and anesthesia providers have access to these meds to these guidelines. You know what I what I always tell people is that it’s not my job necessarily to tell a patient when they should stop their blood thinning medicine because we don’t always know why they’re on it, but what my job is, is based on when they did stop it, I can tell them, using these guidelines what I can safely do for them. We know that there’s options to regional anesthesia for almost every patient, right? There’s general anesthesia, which is so incredibly safe these days that oftentimes, if a patient comes in and I can’t do a spinal because it’s not safe, and their risk of bleeding is too high, I can most likely do a general anesthetic now that, being said, a spinal might be a better option for them. And so that’s, I think, that’s what I would tell an anesthesiologist, is that we shouldn’t be the ones necessarily telling patients when to stop. We should be the ones telling patients what we can do based on when they stopped, and these guidelines help us with that.

Moderator: Any other questions? Yeah, go ahead, please. Dr. Leffert, please.

Dr. Leffert: Yes, I apologize if I could add on labor floors. This should not be left to the individual patient to adjudicate when a patient comes in in labor, these should be discussions that go on in planning on labor floor so everyone’s on the same page. What the guidelines are, what the anticoagulation regimens are, so that we can approach patients in a very organized and rational manner.

Dr. Gupta: And Thom, I want to emphasize that the question from Ajai was about the anesthesiologist, and I think that what I would recommend is, I recommend all anesthesiologists to actually read the whole paper. There’s a lot of educational material in there about understanding how these drugs work, what the implications of different testing are, reversal of those medications if you do get in a situation that you don’t expect, and so instead of just knowing what to do, the more you know about these medications. It is so critical to be able to eloquently make a plan with your surgeons and your primary care physicians and your patients because there’s always going to be a twist or a nuance that doesn’t exactly fit into the exact puzzle. So the authors of this guideline have done a really good job of bringing a lot of complicated information into one place, a great read for any anesthesiologist out there.

Moderator: Another question from Lynn at Trends in Medicine, “Are there specific anticoagulants that are safer than others going into surgery?”

Dr. Kopp: That’s a good question. I would say probably not. You know, every anticoagulant is a little bit different. We use them for different reasons. And when we tell patients to stop is based essentially on the half-life of the medication. So there’s not really one that’s safer than another. Each one is going to have a little bit different of a recommendation, but as long as you follow the recommendations coming off of any of them, should allow you to safely undergo these procedures.

Moderator: Great. Thank you, Dr. Kopp, and thank you for the questions Lynn and others on the call. If that’s all the questions that we have, we’ll go ahead and wrap things up. We will be providing a transcript and a video of this, so we will send those to you once we have those materials available and you’re welcome to email Elizabeth at ASRA Pain Medicine, if you have any further follow-up questions and like to receive a copy of the paper. With that, I will say thank you again to Dr. Kopp, Dr. Gupta, and Dr. Leffert. I’m Thom here at Newswise. Thank you very much. Good luck. Namaste. Have a great day.