Step 11: Managing the anticoagulated patient and timing of LP

Antiplatelets

•NSAIDs: No contraindication

•Ticlopidine: Discontinue 14 days prior

•Clopidogrel: Hold 7 days prior

•GP IIb/IIIa inhibitors: Hold 8–48 h prior Unfractionated heparin

•Subcutaneous

–If the total dose is less than 10,000 units/day, twice daily, there is no contraindication.

–If the total dose is more than 10,000 units/day, more than twice daily, safety is not established.

•Intravenous

–One hour prior and 2–4 h after heparin dose.

–No change in next dose timing even if traumatic.

Low-molecular-weight heparin

•Therapeutic dosing

–24 h after the last dose

•Single daily dosing

–10–12 h after the last dose

–Next dose 4 h after the procedure Warfarin

•International normalized ratio 1.5 or less Fondaparinux

Direct thrombin inhibitors

•Insufficient evidence should be avoided.

•If still necessary

–8–10 h after the last dose

–2–4 h after needle placement Thrombolytics

•Absolute contraindication

Suggested Reading

1.Horlocker TT, Wedel DJ, Rowlingson JC. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy. American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (3rd ed.). Reg Anesth Pain Med. 2010; 35:64–101.

The basis of these recommendations is on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding.

2.Irwin RS, Rippe JM. Cerebrospinal fluid aspiration. In: Irwin and Rippe’s intensive care medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 151.

The text outlines in detail the diagnostic and therapeutic indications of a lumbar puncture along with a review of the techniques involved and the complications one could face during the procedure.

3.Ellenby MS, Tegtmeyer K, Lai S, et al. Lumbar puncture. N Engl J Med. 2006;355:e12.

The article presents a simplified and structured review about lumbar puncture in a step-by-step fashion to guide a physician through its practical and diagnostic aspects.

4.Fink MP. Lumbar puncture. In: Textbook of critical care. 5th ed. Philadelphia: Elsevier; 2005. p. 1885.

This textbook outlines the preparation and technique adopted for successful and safe execution of lumbar puncture in a crisp and to the point way.

Website

1. http://emedicine.medscape.com/article/80773-overview#a01