Regional anesthesia and anticoagulant drugs: A survey of current Italian practice

Improvement in patient post-operative outcomes has been widely demonstrated with regional anesthesia (RA), both with epidural anesthesia and peripheral nerve blocks. However, these techniques can relate to serious complications; hemorrhagic problems are the most feared also for peripheral nerve blocks. In fact, even though complications of peripheral nerve blocks are less serious than central neuraxial blockade, there are several reports of extensive retroperitoneal haematoma following lumbar plexus block in patients using anti-thrombotic drugs. Introduction of more potent anti-thrombotic drugs has increased the risk of bleeding after RA. Hence, in the last years several national anesthesiological societies tried to define guidelines in order to reduce risk of bleeding after RA. As the International Guidelines are very heterogeneous and in Italy we have not recent guidelines, it is important to evaluate how anti-hemostatic drugs are used in clinical practice in Italy. The purpose of our survey is to evaluate how Italian anesthesiologists use different anti-thrombotic drugs in relation with different RA techniques, both neuraxial and peripheral nerve blocks. Data were collected from a questionnaire sent, in March 2011, to anesthesiologists from 66 hospitals, with response rate of 45.45%. The sample size include a wide variety of great hospitals (they performed a total of 203.542 surgical procedures in 2010) with all different surgical settings.Regional analgesia/anesthesia was used in 38.9% of the procedure. We identified a huge variety of responses regarding management of RA and anti-thrombotic drugs. Not all the responders strictly follow guidelines, also because, in many cases, authors from different countries don't agree each other and suggest different behaviors. Most of responders don't follow a common approach and more the agreement between different guidelines, less the differences in anesthetists behavior. In many cases, particularly with ASA and NSAIDs, new drugs (fondaparinux, thienopyridine derivates) and warfarin, the lack of common suggestions in literature leads to a very confused situation, in which everyone has different ways to approach the problem, particularly in time interval they wait between drug administration and block performance/catheter manipulation (also in the same hospital and with the same patient); thus leading, sometimes, to go against main advices coming from different authors (sometimes the only on which they agree), creating dangerous situation for the patient (concomitant use of two anti-thrombotic drugs in people undergoing RA). In conclusion, more studies and guidelines are required to provide a better knowledge on the use of anti-thrombotic drugs, in order to lead to more accurate guidelines and to reduce hemorrhagic risk.