Perioperative Management Of Antiplatelet And Anticoagulant Therapy In Patients Undergoing Interventional Techniques: 2024 Updated Guidelines From The American Society Of Interventional Pain Physicians (ASIPP)

接受介入技术的患者的抗血小板和抗凝治疗的围手术期管理：美国介入疼痛医师协会（ASIPP）2024年更新指南

建议摘要

• The risk of thromboembolic events and associated morbidity and mortality is higher than that of epidural hematoma formation and associated morbidity and mortality with critical management, with the interruption of antiplatelet and anticoagulant therapy preceding interventional techniques, though both risks are significant.
• 血栓栓塞事件及相关发病率和死亡率的风险高于硬膜外血肿形成及相关发病率和死亡率的危险管理，在介入技术之前中断抗血小板和抗凝治疗，尽管这两种风险都很大。
• 证据级别：中
• 推荐强度：中

• Risk stratification categorized multiple interventional techniques into low-risk, moderate or intermediate risk, and high-risk.
• 风险分层将多种介入技术分为低风险、中度或中等风险和高风险。
• 证据级别：低到中
• 推荐强度：中到高

• Risk stratification of patients undergoing interventional techniques on antiplatelet or anticoagulant therapy based on anatomical risk factors, procedural risk factors, bleeding risk factors, anticoagulant risk factors, and medical or physiological status provide a physiologic and clinically appropriate basis in developing the developing the guidelines
• 根据解剖学危险因素、手术危险因素、出血危险因素、抗凝危险因素以及医疗或生理状况对接受抗血小板或抗凝治疗介入技术的患者进行风险分层，为制定指南提供了生理和临床适当的基础。
• 证据级别：中
• 推荐强度：中

• Risk factors with severe degenerative arthritis with or without spinal stenosis, ankylosing spondylitis, osteoporosis, older age, frailty, previous stroke, intracranial bleed, hypertension, diabetes, thrombocytopenia, chronic renal failure, chronic NSAID or steroid therapy, multiple attempts, epidural fibrosis, and previous surgery may increase bleeding observed during the procedure and risk of epidural hematoma.
• 严重退行性关节炎伴或不伴椎管狭窄、强直性脊柱炎、骨质疏松症、老年、虚弱、既往中风、颅内出血、高血压、糖尿病、血小板减少症、慢性肾功能衰竭、慢性非甾体抗炎药或类固醇治疗、多次尝试、硬膜外纤维化、 以前的手术可能会增加手术过程中观察到的出血和硬膜外血肿的风险。
• 证据级别：中
• 推荐强度：中

• Risk stratification should be upgraded to low to moderate or intermediate and moderate or intermediate to high based on other risk factors.
• 根据其他风险因素，风险分层应升级为低至中或中，以及中或中至高。
• 证据级别：低
• 推荐强度：低到中

                          高风险程序

• 颈椎、胸椎和腰椎（L5 以上）层间硬膜外麻醉
• 三叉神经节、眼科和蝶腭神经节阻滞
• 椎间盘造影和椎间盘内手术（腰骶、颈椎和胸椎）
• 背柱和背根神经节刺激器试验和植入
• 鞘内导管和泵植入物
• 椎体成型（骶椎、腰椎、胸椎和颈椎）
• 经皮和内窥镜椎间盘减压手术
• 微创腰椎减压术 (MILD)
• 三叉神经和颅神经阻滞和刺激
• 交感神经阻滞（星状神经节、胸交感神经、内脏神经丛、腹腔神经丛、腰交感神经、腹下神经丛）
• 三叉神经分支神经阻滞（下颌、上颌和其他分支）
• 包括侧向融合的椎间棘突假体
• 骶髂关节融合术

  中风险程序

• 尾部硬膜外注射
• 尾部硬膜外粘连
• L5、S1 腰椎板间硬膜外注射
• 颈椎、胸椎和腰椎 L1和L2 处的经椎间孔

                                      低风险程序

• 触发点和肌内注射（包括梨状肌注射）
• 周围神经阻滞包括下颌神经阻滞和上颌神经阻滞
• 骶髂关节和韧带注射和神经阻滞
• 小关节干预（关节内注射、内侧支和 L5 背支神经阻滞和射频神经切断术）
• 四肢关节腔内注射
• 囊袋翻修和植入式脉冲发生器/鞘内泵更换
• 周围神经刺激试验和植入
• 在 L3、L4、L5 和 S1 处进行腰椎经椎间孔硬膜外注射
• 奇神经节阻滞
• 骶髂关节神经射频
• 三叉神经分支神经阻滞（下颌、上颌和其他分支）

• Discontinuation of aspirin (81 or 325 mg) for 6 days for high-risk procedures. The clinician may choose to continue aspirin (81 or 325 mg) without interruption for low and moderate or intermediate risk procedures or discontinue (81 or 325 mg) for 3 days. Similarly, additional factors may increase the risk and necessitate change in the guidance for low and moderate or intermediate risk patients.
• 对于高风险手术，停用阿司匹林（81或325 mg）6天。
• 对于低、中或中等风险手术，可以选择继续使用阿司匹林（81或325 mg）而不中断，或停用（81或325 mg）3天。
• 证据级别：中
• 推荐强度：中

• Discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days may be considered of moderate and high-risk procedures.
• 大多数NSAID（不包括阿司匹林）停药1 - 2天和4 - 10天可视为中度和高度风险操作。
• 证据级别：低
• 推荐强度：弱

• In patients on anticoagulant therapy with Warfarin, low risk procedures may be performed with INR of ≤3.0, for moderate or intermediate risk procedures an INR of ≤2.0 is recommended with 2 to 3 days of cessation of Warfarin therapy if warranted, and for high-risk procedures an INR of <1.5 is recommended with cessation of Warfarin therapy for 2-3 days if warranted.
• 对于低风险手术，INR≤3.0 是可接受的。
• 对于中等或中等风险手术，推荐 INR≤2.0，并在必要时停用华法林治疗2到3天。
• 对于高风险手术，推荐 INR<1.5，并在必要时停用华法林治疗2到3天。
• 证据级别：低
• 推荐强度：中

• Anticoagulant therapy with direct acting anticoagulants dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto), and Edoxaban (Savaysa, Lixiana) is discontinued for 2 days for high-risk procedures and one day for moderate or intermediate risk procedures. Discontinuation is adjusted to 2 days and 3-4 days for dabigatran (Pradaxa) with creatinine clearance below 50 mL/minute. For low-risk procedures; direct acting oral coagulants may be continued. Based on clinical condition and importance, a shared decision may be made to continue for moderate or intermediate risk procedures with normal renal function.
• 氯吡格雷和普拉格雷对于高风险手术和中等或中度风险手术，停用6天。在低风险手术中继续使用。
• 替格瑞洛在高风险情况下停药5天。
• 噻氯匹定（在美国停产）对于高、中或中等风险手术，停药7天；对于中等风险手术，停药3天；对于低风险手术，可继续使用。
• 证据级别：中
• 推荐强度：中

• Timing of therapy of restoration or restarting is recommended during 12 to 24-hour period for moderate or intermediate risk procedures, and low risk procedures if the decision was made to hold based on risk factors, and 24-48 hours for major risk procedures, based on postoperative bleeding status. If thromboembolic risk is high, antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed, with appropriate assessment and monitoring for clinically significant bleeding.
• 对于中度或中度风险手术，建议恢复或重新开始治疗的时间为12-24小时；对于低风险手术，如果根据风险因素决定暂停，则恢复时间为12-24小时；对于重大风险手术，根据术后出血状态，建议恢复时间为24-48小时。
• 如果血栓栓塞风险高，则可以在进行介入手术后12小时重新开始抗血栓治疗，并适当评估和监测临床显著出血。
• 证据级别：低
• 推荐强度：中

• Diagnosis of epidural hematoma is clinically based on unexpected pain at the site of the injection with rapid neurological deterioration and MRI confirmation. Neurosurgical consult is necessary to avoid neurological sequelae.
• 诊断在临床上是基于注射部位的意外疼痛伴神经功能迅速恶化和MRI确认。
• 神经外科会诊是必要的，以避免神经后遗症。
• 证据级别：中
• 推荐强度：中

• If thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure.
• 如果血栓栓塞风险高，则可在停止抗凝剂期间开始低分子量肝素桥接治疗，并且可在疼痛手术前24小时停用低分子量肝素。
• 证据级别：低
• 推荐强度：弱

• Shared decision making between the patient, the pain specialist, and the treating physicians if cessation is contemplated is recommended for consideration of all the appropriate risks associated with continuation or discontinuation of antiplatelet or anticoagulant therapy
• 建议患者、疼痛专家和治疗医生共同决定是否考虑停止治疗，以考虑与继续或停止抗血小板或抗凝治疗相关的所有适当风险。
• 证据级别：中
• 推荐强度：高