Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic therapy
- METHODOLOGY
A comprehensive search for guidelines was done to identify the most relevant ones to consider for adaptation. For the literature review, potentially relevant clinical studies were identified via electronic and manual searches of the literature. The updated searches covered a 10-year period from January 1, 2015, to December 31, 2025. The inclusion/exclusion criteria that were followed in the search and retrieval of guidelines are adapted.
We selected guidelines only if they are:
- Evidence-based guidelines.
- National and/or international guidelines.
- Guidelines published from 2015 to 2025.
- Peer reviewed publications.
- Guidelines written in English language.
We Excluded guidelines that are:
- Written by a single author not on behalf of an organization as guideline to be valid and comprehensive, ideally requires multidisciplinary input.
§ Published without references as the panel needs to know whether a thorough literature review was conducted and whether the current evidence was used in the preparation of the recommendations.
All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members of the GDG. The panel decided on a cut-off point or ranked the guidelines (any guideline scoring above 50% on the rigor dimension was retained).
Guidelines used in the Adaptation Process:
The basic elements of the international guidelines for the management of regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy published by international societies can be successfully implemented in the practice of regional anesthesia worldwide. The Guidelines Development Group (GDG) for the Egyptian Board of Anesthetics, Surgical Intensive Care, and Pain Management has adopted with modification:
1. Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine. Evidence-Based Guidelines (fifth edition). Regional Anesthesia & Pain medicine. 2025 http://orcid.org/0000-0003-2997-5445 (Reference No. 1)
2. Horlocker TT , Vandermeuelen E , Kopp SL , et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fourth Edition). Reg Anesth Pain Med 2018;43:263–309. doi:10.1097/AAP.0000000000000763 (Reference No. 4)
3. Kietaibl S , Ferrandis R , Godier A , et al . Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022;39:100-32.
doi:10.1097/EJA.0000000000001600 (Reference No. 5)
4. Narouze S, Benzon HT, Provenzano D , et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2018;43(3):225-262. doi:10.1097/AAP.0000000000000700 (Reference No. 6)
5. Benzon HT, Nelson AM, Patel AG , et al. Literature review of spinal hematoma case reports: causes and outcomes in pediatric, obstetric, neuraxial and pain medicine cases. Reg Anesth Pain Med 2024. doi:10.1136/rapm-2023-105161 (Reference No. 7)
6. Douxfils J , Ageno W , Samama C-M , et al. Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J Thromb Haemost 2018;16:209–19. doi:10.1111/jth.13912 (Reference No. 17)
7. Douketis JD , Spyropoulos AC , Murad MH , et al. Executive Summary: Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022;162:1127–39. doi:10.1016/j.chest.2022.08.004 (Reference No. 58)
8. Leffert LR, Dubois HM, Butwick AJ , et al. Neuraxial Anesthesia in Obstetric Patients Receiving Thromboprophylaxis With Unfractionated or Low-Molecular-Weight Heparin: A Systematic Review of Spinal Epidural Hematoma. Anesth Analg 2017;125:223–31. doi:10.1213/ANE.0000000000002173 (Reference No. 93)
9. Tsui BCH, Kirkham K, Kwofie MK , et al. Practice advisory on the bleeding risks for peripheral nerve and interfascial plane blockade: evidence review and expert consensus. Can J Anaesth 2019;66:1356–84. doi:10.1007/s12630-019-01466-w (Reference No. 100)
➡️Strength of Recommendations
The strength of a recommendation communicates the importance of adherence to the recommendation.
Strong Recommendations | The GDG found that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted.
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Conditional Recommendations | This means that the GDG found that there is: ▪ Greater uncertainty about the strength of evidence, or ▪ The recommendation may account for a greater variety in patient values and preferences, or ▪ The resource use makes the intervention suitable for some, but not for other locations. Conditional recommendations are still the best available evidence to date, and it can be adopted if it meets the conditions mentioned with it.
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Good Practice Statement (GPS) | Statements based on expert opinion of respected authorities, and the guidelines development group.
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