Influence of antithrombotic medication on size and neurological outcome of spinal epidural hematoma after neuraxial anesthesia: a systematic review.

INTRODUCTION: Anticoagulation guidelines were developed to reduce the potential risk of epidural bleeding following neuraxial anesthesia. However, the influence of antithrombotic medication on size of spinal epidural hematoma and neurological outcome is unclear. Therefore, our aim was to analyze whether there is a correlation. METHODS: The study was registered at Prospero (CRD42021285833). A systematic search in MEDLINE, EMBASE, CENTRAL, Web of Science and Google Scholar was conducted in August 2023 for studies reporting spinal epidural hematoma following neuraxial anesthesia. Primary endpoints were segmental extension and neurological outcome. Secondary endpoints were age, sex, body mass index, predisposition, American Society of Anesthesiologists physical status, complicated puncture, multiple punctures, bloody puncture, successful puncture, catheter usage, needle size and worst neurological deficit before treatment. Prespecified multivariate regression and propensity score matching was performed. Publications reporting on more than one patient were critically appraised. RESULTS: A total of 345 cases reported in 304 publications were included. Size of hematoma was not significantly different (antithrombotic medication: OR 0.11, 95% CI (-0.67 to 0.89), p=0.78, 'non-guideline adherent' for puncture/removal: OR 0.13, 95% CI (-0.92 to 1.18), p=0.81). Patients receiving antithrombotic medication were more likely to have persistent neurological deficit (OR 2.00, 95% CI 1.24 to 3.23), p<0.01). Significance persisted after propensity score matching (p=0.04). Patients with non-guideline adherence had a 3.42 higher chance of persistent neurological deficit (95% CI 1.71 to 6.86, p<0.001). DISCUSSION: Antithrombotic medication is not significantly associated with hematoma size; however, the use of antithrombotic medication doubled the risk for persistent neurological deficit after spinal epidural hematoma.

Pre- and perioperative aspects of dermatosurgery.

Dermatosurgery occupies an exceptional position among all surgical disciplines. Above all, this includes the fact that, with very few exceptions, the vast majority of surgical interventions can be performed under local or regional anesthesia, usually in smaller procedure rooms that are spatially separated from larger operating suites. Thus, peri- and postinterventional patient monitoring is the responsibility of the dermatosurgeon and his team. Though inherently smaller, this team still has to observe numerous perioperative requirements that - in larger surgical specialties - would be attended to by a host of various specialists working in concert. Said requirements include hygienic aspects, knowledge concerning pre- and intraoperative patient monitoring, managing surgical site infections, adequate postsurgical pain management, as well as detailed pharmacological knowledge with respect to common local anesthetics and the toxic and allergic reactions associated therewith. Not only does this require interdisciplinary collaboration and shared responsibility for the patient. It also necessitates the development and implementation of quality-oriented and evidence-based guidelines that, in the dermatosurgical setting, usually extend far beyond the scope of the specialty per se. The objective of the present CME article is the condensed presentation of interdisciplinary aspects relating to the most important perioperative issues.

Prä- und perioperative Aspekte der Versorgung dermatochirurgischer Patienten.

Die Dermatochirurgie nimmt hinsichtlich vieler Punkte eine Sonderstellung unter den operativen Fächern ein. Hierzu gehört in erster Linie die Tatsache, dass bis auf wenige Ausnahmen fast alle Eingriffe traditionell in Lokal- bzw. Regionalanästhesie und oft auch in räumlich-infrastruktureller Trennung von den großen Zentral-Operationssälen stattfinden können. Die peri- und postoperative Überwachung obliegt dabei dem dermatochirurgischen Operationsteam. Das sui generis kleinere OP-Team hat somit eine ganze Reihe perioperativer Notwendigkeiten zu beachten, um die sich in den "großen" chirurgischen Fächern eine Vielzahl verschiedener beteiligter Fachgruppen gemeinsam kümmern. Hierzu gehören neben Hygieneaspekten, Kenntnissen in der Überwachung der Patienten sowie dem Aspekt der surgical site infections auch Fragen zur postoperativen Schmerztherapie sowie detailliertes pharmakologisches Wissen über die zur Anwendung kommenden Lokalanästhetika und das Handling der damit assoziierten toxischen und allergischen Reaktionen. Eine interdisziplinäre Zusammenarbeit und Verantwortung für den Patienten ist notwendig und erfordert die Erarbeitung und Umsetzung qualitätsorientierter und evidenzbasierter Handlungsanweisungen, die im dermatochirurgischen OP-Setting meist weit über das eigentliche Fach hinausgehen. Ziel dieses Weiterbildungsartikels soll die komprimierte Darstellung der genannten fachübergreifenden Standpunkte bezüglich der wichtigsten perioperativen Aspekte sein.