Background: 

The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures.

Study design: 

Review of the literature and development of guidelines based on best evidence synthesis.

Objectives: 

To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications.

Methods: 

Development of consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest.

Results: 

A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy.

Limitations: 

The continued paucity of literature with discordant recommendations.

Conclusion: 

Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.

背景：

在接受抗凝和抗血小板治疗的慢性疼痛患者中，介入技术的实施频率持续增加。

研究设计：

文献综述和基于以下内容的指南制定

目的：

提供关于使用抗凝和/或抗血小板药物的患者在介入技术期间出血和血栓形成风险评估的文献的最新简明评价。

结果：

共有34名作者参与了这些指南的制定。其中29人参加了投票过程。共提出了20项建议。总体而言，20个项目中的16个获得了100%的可接受性。第二轮和第三轮投票的项目总数减少到18个。16个项目 (89%) 的最终结果为100%接受。3位作者的2项声明（声明6和7）和建议存在分歧。其余2个项目的接受率为94%和89%。分歧和异议由Byron J. Schneider,MD提出，建议将所有经椎间孔药物归类为低风险，而Sanjeeva Gupta,MD希望所有经椎间孔药物归类为中等风险。第二个分歧与Vivekanand A. Manocha,MD相关，建议颈椎和胸椎经椎间孔手术为高风险手术。因此，通过适当的文献综述，为接受抗凝剂和抗血小板药剂的患者的围手术期管理制定了基于共识的声明，包括以下内容：血栓栓塞风险估计、出血风险估计和确定重新开始抗凝剂或抗血小板药剂治疗的时间。提供了风险分层，将介入技术分为低风险、中等或中等风险和高风险三类。此外，在低风险和中等或中等风险类别中，多次提出反对停止抗凝或抗血小板治疗的建议。

限制：

建议不一致的文献持续缺乏。