Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.
BACKGROUND
Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice.


METHODS
The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008.


RESULTS
Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks.


CONCLUSIONS
Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.
Breivik
H
H
Section for Anaesthesiology and Intensive Care Medicine, University of Oslo, Rikshospitalet, Oslo, Norway. harald.breivik@medisin.uio.no
Bang
U
U
Jalonen
J
J
Vigfússon
G
G
Alahuhta
S
S
Lagerkranser
M
M
D000767:Anesthesia, Epidural / Q000009:adverse effects / Q000592:standards*; D000775:Anesthesia, Spinal / Q000009:adverse effects / Q000592:standards*; D000776:Anesthesiology / Q000592:standards*; D000925:Anticoagulants / Q000008:administration & dosage / Q000037:antagonists & inhibitors; D003422:Critical Care / Q000592:standards*; D019317:Evidence-Based Medicine; D046748:Hematoma, Epidural, Spinal / Q000517:prevention & control*; D006801:Humans; D012537:Scandinavian and Nordic Countries; D054556:Venous Thromboembolism / Q000517:prevention & control
D000925:Anticoagulants