CAPÍTULO I: Antecedentes de la Gestión de Configuración de Software
1.5. Análisis del estado del proyecto en sus inicios en cuanto a la Gestión de
After Last Dose of Medication Before High Risk
Interventional Techniques Are
Performed
Time to Wait After Last Dose
of Medication Before Caudal or Paravertebral
Interventional Techniques are
Performed
NSAIDS Do not stop Do not stop Do not stop 12 hours to 2 weeks Do not stop Do not stop Aspirin
Low dose aspirin Do not stop Do not stop Do not stop None to 12 hours Do not stop Do not stop High dose aspirin May stop for 7 days May stop for 7 days 7 days 3 days Do not stop NA Antiplatelet Agents
Phosphodiesterase Inhibitors Dipyridamole
(Persantine) Do not stop Do not stop Do not stop Do not stop NA NA
Cilostazol (Pletal) Do not stop Do not stop NA NA 42 hrs NA
Aggrenox (dipyridamole
plus aspirin) Do not stop Do not stop NA NA NA NA
Platelet Aggregation Inhibitors
Clopidogrel (Plavix) May stop for 7 days May stop for 7 days 5-10 days 5 days 7 days 7 days Prasugrel (Effient) May stop for 7 days May stop for 7 days 7-10 days 5 days 7-10 days 7 days Ticlopidine (Ticlid) May stop for 14 days May stop for 14 days 5-10 days 5 days 10 days 10 days Vitamin K Antagonists
Warfarin
When INR is 1.4 or less, both warfarin may be stopped for
1-5 days.
When INR is 2.0 or less, both warfarin may be stopped for
1-5 days.
When INR is 1.4 or less, stop for at least
5 days.
When INR is below 1.4-2.2 stop for 1-4
days
When INR is 1.4 or below
When INR is less than 1.4. Stop for
4-10 days Thrombin Inhibitors
Dabigatran (Pradaxa)*
Normal renal function 2-4 days
Impaired renal function (creatinine
clearance < 50 mL/
min) at least 5 days
Normal renal function 24 hrs.
Impaired renal function (creatinine
clearance < 50 mL/
min) at least 5 days
NA NA NA NA
Anti-Xa Agents
Rivaroxaban (Xarelto) 24 hrs 24 hrs NA NA NA NA
Heparins Heparin (treatment)
-IV 6 hrs and a PTT
within normal limits 6 hrs and a PTT within normal limits
10-12 hrs and a PTT within normal limits
4 hrs and a PTT within normal
limits
4-6 hrs and a PTT within normal limits
6 hrs and a PTT within normal
limits Heparin (treatment)
- SC 12 hrs and aPTT
within norm al limits 12 hrs and aPTT within normal limits
10-12 hrs and a PTT within normal limits
4 hrs and a PTT within normal
limits
4-6 hrs and a PTT within normal limits
12 hrs and a PTT within normal
limits
LMWH 12 hrs 12 hrs 10 hrs 10-24 hrs 12 hrs 12-24 hrs
*These recommendations are dependant on multiple factors including the individual patient, risk factors, and cardiologist opinion.
LMWH = Low Molecular Weight Heparin; PTT = Partial Thromboplastin Time; NSAID = Nonsteroidal Anti-inflammatory Drugs; INR = Interna-tional Normalized Ratio; hrs = Hours
tions for various agents are dependent on multiple fac-tors including the individual patient, risk facfac-tors, and cardiologist’s opinion. This must be a shared decision.
The risks of thromboembolic phenomenon and bleed-ing with hematoma formation must be considered equally. The recommendations provided here are based on previous guidelines and comprehensive literature reviews.
• NSAIDS, including low dose aspirin, do not increase the risk of spinal epidural hematoma and are not a contraindication for interventional techniques (evi-dence –good).
• However, high dose aspirin and combination of multiple drugs should be taken into consideration and may or may not be discontinued based on clinical judgment of individual risk and benefits as-sessment. In this regard, the simultaneous use of multiple agents that possess anticoagulant proper-ties (e.g. NSAIDs or aspirin along with SSRIs, fish oil, etc.) will increase the risk of morbidity and/or mortality.
• Phosphodiesterase inhibitors including dipyridam-ole (Persantine), Aggrenox (dipyridamPhosphodiesterase inhibitors including dipyridam-ole plus as-pirin), and cilostazol (Pletal) do not appear to in-crease the risk of spinal epidural hematoma and are not a contraindication for interventional tech-niques (evidence – fair).
• They may or may not be discontinued prior to in-terventional techniques.
• Platelet aggregation inhibitors including ticlopi-dine (Ticlid), clopidogrel (Plavix), and prasugrel (Ef-fient) may be continued or discontinued prior to interventional techniques (evidence – fair).
• Based on patient factors and managing cardiolo-gist’s opinion, if a decision is made to discontinue, the current recommendations are that they may be discontinued for 7 days with clopidogrel and prasu-grel and/or 10 to 15 days with ticlopidine (evidence – fair).
• There is also emerging evidence that discontinua-tion of 3 days may be effective (evidence – limited).
• Warfarin may be continued or discontinued based on INR achieved during therapy (evidence – good).
• For high risk interventional techniques including interlaminar epidural injections, percutaneous ad-hesiolysis, disc decompression, sympathetic blocks, and placement of implantables, warfarin should be discontinued for an appropriate period of time and INR of 1.4 or less must be achieved (evidence – good).
• For intermediate risk procedures such as caudal epidural injection, paravertebral interventional techniques, and peripheral joint injections, warfa-rin should be continued for an appropriate period of time and INR of 2 or less may be considered (evi-dence – limited).
• Unfractionated heparin or LMWH may be discon-tinued approximately 12 hours prior to providing interventional techniques (evidence – limited).
• Dabigatran (Pradaxa) may be stopped 2 to 4 days for major interventional techniques with high risk of bleeding in patients with creatinine clearance greater than 50 mL per minute. For low risk or paravertebral interventional techniques and cau-dal, it may be stopped for one day in patients with normal renal function. May be stopped at least 4 to 5 days for those with creatinine less than 50 mL per minute. (evidence – limited)
• Rivaroxaban (Xarelto) may be stopped for one day or longer (evidence-limited).
4.0 c
onclusionBased on the available literature including guide-lines, the recommendations in patients with antithrom-botic therapy for therapy prior to interventional tech-niques are provided.
A
cknowledgMentsThe authors wish to thank Vidyasagar Pampati, MSc, for statistical assistance; Sekar Edem for assistance in the search of the literature; Alvaro F. Gómez, MA and Laurie Swick, BS for manuscript review; and Tonie M.
Hatton and Diane E. Neihoff, transcriptionists, for their assistance in preparation of this manuscript. We would like to thank the editorial board of Pain Physician for review and criticism in improving the manuscript.
Author Affiliations
Dr. Manchikanti is Medical Director of the Pain Management Center of Paducah, Paducah, KY, and Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY.
Dr. Falco is Medical Director of Mid Atlantic Spine
& Pain Physicians, Newark, DE; Director, Pain Medicine Fellowship Program, Temple University Hospital, Phila-delphia, PA; and Associate Professor, Department of PM&R, Temple University Medical School, Philadelphia, PA.
Dr. Benyamin is the Medical Director, Millennium Pain Center, Bloomington, IL, and Clinical Assistant
Pro-fessor of Surgery, College of Medicine, University of Il-linois, Urbana-Champaign, IL.
Dr. Caraway, St. Mary’s Pain Relief Center, Hunting-ton, WV.
Dr. Alan D. Kaye is Chairman and Professor, Depart-ment of Anesthesia, LSU Health Science Center, New Orleans, LA.
Dr. Helm is Medical Director, The Helm Center for Pain Management, Laguna Hills, CA.
Dr. Wargo is an Interventional Pain Physician at the McFarland Clinic, Mary Greeley Medical Center, Ames, IA.
Dr. Hansen is Medical Director, Pain Relief Centers, Conover, NC.
Dr. Parr is Medical Director, Premier Pain Center, Covington, LA.
Dr. Singh is Medical Director, Spine Pain Diagnostics Associates, Niagara, WI.
Dr. Swicegood is Medical Director, Advanced Inter-ventional Pain and Diagnostics of Western Arkansas, Fort Smith, AR
Dr. Smith is Professor and Director of Pain Manage-ment for Albany Medical College, DepartManage-ment of Anes-thesiology, Albany, NY.
Dr. Schultz is the Medical Director of MAPS Medical Pain Clinics, Minneapolis, MN.
Dr. Malla is an Interventional Pain Physician at the Pain Management Center of Paducah, Paducah, KY.
Dr. Hirsch is Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief
of Interventional Radiology, Director of Endovascular Neurosurgery and Neuroendovascular Program, Mas-sachusetts General Hospital; and Associate Professor, Harvard Medical School, Boston, MA.
Conflict of Interest:
Dr. Falco is a consultant for St. Jude Medical Inc.
and Joimax Inc.
Dr. Benyamin is a consultant with Bioness and Nev-ro; serves on the advisory boards of Vertos Medical and Nuvo Pharma; teaches/lectures for Vertos Medical, Bos-ton Scientific, Neurotherm, and Bioness; and receives research/grants from Alfred Mann Foundation, Teknon Foundation, Spinal Restoration, Inc., Bioness, Boston Scientific, Vertos Medical, Medtronic, Kimberly Clarke, Epimed, BioDelivery Sciences International, Inc., Thera-vance, Mundipharma Research, Cephalon/Teva, Astra-Zeneca, and Purdue Pharma, LP.
Dr. Caraway is a consultant for Medtronic, Inc., Spi-nal Modulation, Inc., and Vertos, Inc.
Dr. Kaye is a speaker for Depomed, Inc.
Dr. Helm is a clinical investigator with Epimed and receives research support from Cephalon/Teva, Astra-Zeneca, and Purdue Pharma, LP. He has attended an advisory group meeting for Activas.
Dr. Schultz is a paid consultant for Medtronic.
Dr. Hirsch has received fees from CareFusion in the past 12 months. He participated in an Aetrium focus group and received compensation.
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