Rev Esp Anestesiol Reanim.

2015;62(10):557---564

Revista Española de Anestesiología

y Reanimación
www.elsevier.es/redar

ORIGINAL ARTICLE

National survey on thromboprophylaxis

and anticoagulant or antiplatelet management
in neurosurgical and neurocritical patients夽
E. Vázquez-Alonso a,∗ , N. Fábregas b , P. Rama-Maceiras c , I. Ingelmo Ingelmo d ,
R. Valero Castell b , L. Valencia Sola e , F. Iturri Clavero f , Neuroscience Subcommittee of
the Spanish Anaesthesia Society

a
Servicio de Anestesiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
b
Servicio de Anestesiología, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
c
Servicio de Anestesiología, Complejo Hospitalario Universitario Juan Canalejo, A Coruña, Spain
d
Servicio de Anestesiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
e
Servicio de Anestesiología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
f
Servicio de Anestesiología, Hospital Universitario Cruces, Bilbao, Vizcaya, Spain

Received 24 June 2014; accepted 19 January 2015

Available online 9 September 2015

KEYWORDS Abstract
Neuroanaesthesia; Objectives: To determine the protocols used by Spanish anaesthesiologists for thromboprophy-
Survey; laxis and anticoagulant or antiplatelet drugs management in neurosurgical or neurocritical care
Thromboprophylaxis; patients.
Antiplatelet Materials and methods: An online survey with 22 questions, with one or multiple options,
treatment; launched by the Neuroscience Subcommittee of the Spanish Anaesthesia Society and available
Neurosurgery between June and October 2012.
Results: Of the 73 hospitals included in the National Hospitals Catalogue, a valid response to the
online questionnaire was received by 41 anaesthesiologists from 37 sites (response rate 50.7%).
Only one response per site was used. A specific protocol was available in 27% of these cen-
tres. Mechanical thromboprophylaxis is used, intraoperatively or postoperatively, in 80%, and
pharmacological treatment is used by 75% of respondents. Enoxaparin was the most frequent
heparin used in craniotomy patients (78%). Craniotomies were performed maintaining acetyl-
salicylic acid treatment in patients with coronary stents and double anti-platelet treatment in
half of the centres.

夽 Please cite this article as: Vázquez-Alonso E, Fábregas N, Rama-Maceiras P, Ingelmo Ingelmo I, Valero Castell R, Valencia Sola L,

et al. Encuesta nacional sobre la tromboprofilaxis y el manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y
neurocríticos. Rev Esp Anestesiol Reanim. 2015;62:557---564.
∗ Corresponding author.

E-mail address: [email protected] (E. Vázquez-Alonso).

2341-1929/© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España, S.L.U. All rights
reserved.
558 E. Vázquez-Alonso et al.

Conclusions: Mechanical thromboprophylaxis is used more frequently than the pharmacological

approach in neurosurgical or neurocritical populations in Spanish hospitals. Management of
patients under previous anticoagulant treatment was highly heterogeneous among hospitals
included in this survey. Previous antiplatelet treatment is modified depending on primary or
secondary prescription.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published
by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Encuesta nacional sobre la tromboprofilaxis y el manejo de los anticoagulantes

Neuroanestesia; y antiagregantes en pacientes neuroquirúrgicos y neurocríticos
Encuesta descriptiva;
Tromboprofilaxis; Resumen
Antiagregantes; Objetivos: Conocer la práctica clínica de los anestesiólogos españoles en la tromboprofilaxis y el
Neurocirugía manejo de los anticoagulantes y antiagregantes en pacientes neuroquirúrgicos y neurocríticos.
Material y métodos: Encuesta diseñada desde la Sección de Neurociencia de la Sociedad
Española de Anestesiología y Reanimación, con 22 preguntas, difundida y contestada en formato
electrónico, disponible entre junio y octubre de 2012.
Resultados: De los 73 centros hospitalarios con servicio de Neurocirugía incluidos en el Catá-
logo Nacional de Hospitales, se recibió respuesta válida a la encuesta on line por parte de
41 anestesiólogos de 37 centros (tasa de respuesta del 50,7%). Se consideró una respuesta de
cada centro. Solo el 27% de los centros respondedores disponían de un protocolo escrito especí-
fico para el manejo de estos pacientes. La tromboprofilaxis mecánica se utilizó hasta en un 80%,
aunque de forma variable, y la farmacológica en un 75% de los centros. La enoxaparina fue la
heparina de bajo peso molecular más utilizada en pacientes sometidos a craneotomía (78%). En
la mitad de los centros respondedores se realizaron craneotomías manteniendo el tratamiento
con ácido acetilsalicílico en los pacientes con antecedentes de cardiopatía isquémica, stent
coronario y antiagregación dual.
Conclusiones: La tromboprofilaxis mecánica es más utilizada que la farmacológica en la
población neuroquirúrgica de nuestro país. El manejo de los pacientes tratados previamente
con anticoagulantes presenta una marcada variabilidad clínica entre los diferentes hospitales,
mientras que el tratamiento con antiagregantes se modifica en función de si se trata de profilaxis
primaria o secundaria.
© 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado
por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction The VTE prevention method of choice in neurosurgery has

traditionally been mechanical thromboprophylaxis, such as
Although the incidence of venous thromboembolism (VTE) graduated compression stockings (GCS) and/or intermittent
in neurosurgical patients can be as high as 50%,1,2 the safety pneumatic compression (IPC) systems. The risk of bleeding
of pharmacologic thromboprophylaxis in these patients associated with low-molecular-weight heparins (LMWH) has
compared with orthopaedic surgery patients, for exam- limited their use in neurosurgery. Nevertheless, pharmaco-
ple, is unclear. The controversy is due to the morbidity logic thromboprophylaxis has been used in many patients is
accompanying the onset of haemorrhage in neurocriti- recent years, although opinions differ greatly with regard
cal patients or any neurosurgical procedure, and the risk to clinical practice.5 No clinical evidence is currently avail-
of permanent complications or even death. The risk of able on the best management strategy for neurosurgical
VTE becoming symptomatic in patients that have under- patients on chronic anticoagulant or antiplatelet therapy
gone intracranial surgery can be as high as 31%.3 These at high risk for thrombosis (with mechanical heart valves,
patients are considered to be at high risk for developing comorbid atrial fibrillation, history of VTE, thrombophilia
VTE during the postoperative period. This is particularly or coronary stent). Vitamin K antagonist oral anticoagu-
true of patients undergoing craniotomy for tumour lants should be replaced with LMWH as bridging therapy.
resection.4,5 Patients undergoing spinal surgery are also at In patients previously treated with antiplatelet agents or
risk from procedure-related factors, such as the ‘‘tuck’’ new oral anticoagulants, however, this is not the established
position in which the hips and knees are flexed, or from approach. In 2011, the Spanish Society of Anaesthesiol-
spinal cord retraction. ogy and Intensive Care Medicine (SEDAR) published clinical
National survey on thromboprophylaxis and anticoagulant/antiplatelet management 559

practice guidelines on the perioperative management of 90

non-cardiac surgery patients receiving antiplatelet agents. 80
These recommendations included a strategy for patients 70
scheduled for high bleeding risk surgery, such as intracranial 60
surgery, who are at high risk for thrombosis if antiplatelet
50
therapy is interrupted.6 These guidelines recommend sus-
40
pending clopidogrel between 3 and 5 days prior to surgery,
replacing high dose acetylsalicylic acid (ASA) with a lower 30

dose of 100 mg, and evaluating suspension of ASA from 2 to 20

5 days before surgery when strictly necessary. 10
The main aim of SEDAR’s neuroscience team was to 0
gather information by means of a nation-wide survey on GCS IPC Foot pump LMWH
thromboprophylaxis and management of anticoagulant and
antiplatelet agents in clinical practice in neurosurgical Figure 1 Mechanical and pharmacologic thromboprophylaxis
and neurocritical patients. reported in the survey. The results are expressed as the number
(%) of hospital out of the total number of respondent hospitals.
GCS: gradual compression stockings; IPC: intermittent pneu-
Materials and methods matic compression; LMWH: low-molecular-weight heparin.

Members of SEDAR’s neuroscience department drew up 80

a questionnaire which was uploaded to the association’s 70

website (http://www.anestesiados.com/encuesta-sedar- 60
neurocirugia/) in ‘‘Google Docs’’ format. The survey was 50
promoted on the association’s website, on the anestesi- 40
ados.com website, and also on its corresponding Twitter 30
account (@anestesiados). The questionnaire was aimed 20
at the anaesthesiology departments of Spanish hospitals 10
offering neurosurgery services, and was available online 0
from June to October 2012. It comprised 22 questions, most ri n ar
in
ar
in rin rin ux
a pa ip op pa pa a rin
of which were single- or multiple-choice. In single-choice r te a
ox em ad al nz ap
En B N D Ti nd
questions, respondents had to indicate the option that best Fo
described normal clinical practice in their hospital. In the
Figure 2 Low-molecular-weight heparin thromboprophylaxis
first question, anaesthesiologists were asked to name the
in craniotomy patients. The results are expressed as the number
hospital to which they were attached, in order to avoid
(%) of hospital out of the total number of respondent hospitals.
receiving 2 questionnaires from the same centre, as only
1 questionnaire would be evaluated from each centre. If
2 questionnaires were returned by the same hospital, the
ogists from the 73 hospitals offering neurosurgery services
department in question was asked to validate only one,
included in the National Catalogue of Hospitals maintained
and the other was discarded. The survey did not include an
by the Spanish Ministry of Health, Social Services and
informed consent form, as consent was implicit in partici-
Equality7 (a response rate of 50.7%). Only 27% of the hos-
pation. The questionnaire was divided into 6 sections. The
pitals had specific written protocols for the perioperative
first 2 concerned mechanical VTE prophylaxis measures and
management of anticoagulant/antiplatelet agents and/or
pharmacologic measures in, firstly, patients not receiving
VTE in neurosurgical and/or neurocritical patients.
prior anticoagulant/antiplatelet therapy; secondly, in
The mechanical VTE prophylaxis systems used in each
patients previously receiving coumarin derivatives; and
hospital are shown in Fig. 1. In total, 56% of hospitals used
finally, in patients previously receiving antiplatelet agents.
IPC in the intraoperative period, mostly (61%) in the imme-
The last 4 sections contained questions on emergency
diate postoperative period in the recovery room. The use of
interventions, minimally invasive surgery, spinal surgery,
mechanical prophylaxis, however, fell to just 8% after the
and traumatic brain injury (TBI). An example of the full
patient was transferred to the ward. One-fourth of hospitals
questionnaire can be downloaded from Appendix (online).
did not use IPC systems at any time.
The descriptive analysis of the data was performed
In respect to pharmacologic treatment in patients
on IBM® SPSS® v. 19.0 Statistics (IBM Corp., Armonk, NY,
not previously receiving antiplatelet/anticoagulant ther-
USA). Descriptive results are expressed as number and
apy, 75% of hospitals used thromboprophylaxis with LMWH
percentage of responses in each section. The chi-square
in patients undergoing craniotomy. The heparin most fre-
test was performed, and statistical significance was set at
quently used was enoxaparin (78%); none of the hospitals
p < 0.05.
used tinzaparin or fondaparinux in their thromboprophylaxis
protocol (Fig. 2). In these cases, 11% of hospitals pre-
Results scribed preoperative LMWH administered between 12 and
24 h before surgery. The point at which postoperative admin-
A total of 41 completed questionnaires were received, of istration was started varied greatly, although it was most
which 4 were duplicates and therefore discarded. Valid frequently started at 24 h post-surgery (36% of hospitals);
online questionnaires were received from 73 anaesthesiol- 17% reported starting at 48 h post surgery, and 6% at 72 h.
560 E. Vázquez-Alonso et al.

60
Table 1 Suspension and restart of perioperative treatment
with low-molecular-weight heparin in patients undergoing 50
craniotomy.
40
Time (h) Last Postoperative
preoperative restart of 30
dose therapy
20
12 15 (41) 7 (19)
24 19 (51) 9 (24) 10
36 1 (3) 5 (14)
72 --- 7 (19) 0

>72 --- 2 (5) A B C D

Results expressed as number of respondent hospitals (%). Figure 3 Craniotomy performed in patients maintaining
acetylsalicylic acid treatment according to the results of the
survey, according to indication for antiplatelet therapy. The
In patients previously receiving anticoagulant therapy with results are expressed as the number (%) of hospital out of the
coumarin derivatives due to a high risk for thromboembolism total number of respondent hospitals. (A) Primary prophylaxis
(for example, documented thrombophilia, atrial fibrillation with less than 3 risk factors. (B) Primary prophylaxis with 3 or
with a history of embolism, atrial fibrillation with a his- more risk factors. (C) Ischaemic heart disease, coronary stent
tory of mechanical heart valves, mechanical heart valve in and single antiplatelet therapy. (D) Ischaemic heart disease,
place for at least 3 months, etc.) who received preopera- coronary stent and combination antiplatelet therapy.
tive LMWH prior to craniotomy, the last therapeutic dose
of LMWH was administered 24 h prior to surgery in 51% of
hospitals (Table 1). the primary prophylaxis with less than 3 risk factors group
In patients with less than 3 risk factors who were vs primary prophylaxis with 3 or more risk factors groups
scheduled for craniotomy and had previously received (p < 0.001) (Fig. 3). If antiplatelet therapy was suspended
antiplatelet agents as primary prevention (Table 2), most prior to craniotomy in patients at high risk of thrombosis,
hospitals suspended ASA 5 days prior to surgery (78%). In resumption of treatment in the postoperative period varied
patients with 3 or more risk factors, only 49% hospitals sus- greatly, although it was usually restarted at 24 h (46%).
pended antiplatelet therapy with ASA prior to surgery. When With regard to minimally invasive cranial surgery, such
antiplatelet therapy was given as sole therapy for ischaemic as stereotaxic surgery, endoscopic third ventriculostomy,
heart disease treated with a coronary stent, only 37% of etc., 70% of hospitals used the same thromboprophylaxis as
hospital suspended administration of ASA. In total, 46% of that used in craniotomy. The management of spinal surgery
hospitals performed craniotomy while maintaining oral ASA patients previously treated with antiplatelet agents is
therapy at a dose of 100 mg every 24 h. In patients with shown in Table 3. In the postoperative period, thrombo-
a stent who were receiving combination antiplatelet ther- prophylaxis in patients with no risk factors for VTE mainly
apy with ASA and clopidogrel, 44% of hospitals suspended consisted of LMWH (66%). This increased significantly to 91%
antiplatelet therapy, while 53% performed craniotomy while in the case of patients with risk factors for VTE. In emer-
maintaining ASA therapy at a dose of 100 mg every 24 h gency craniotomy in patients taking coumarin derivatives,
(Table 3). The greater the number of risk factors, the the most common reversal technique used was administra-
higher the percentage of hospitals performing craniotomy tion of prothrombin complex concentrate (80% of hospitals),
with ASA. Statistically significant differences were found in followed by fresh frozen plasma (69%) and vitamin K (66%).
In TBI patients with no previous anticoagulant treatment,
mechanical VTE thromboprophylaxis was usually used (GCS
44%, and IPC 44%). In 35% of hospitals, thromboprophylaxis
Table 2 Risk factors for thrombosis in patients with with LMWH was used, while in 24% no thromboprophylaxis
antiplatelet therapy. measures were taken. In the case of TBI patients with pre-
Age vious anticoagulant treatment, the percentage of hospitals
DM using LMWH for thromboprophylaxis increased to 52%. This
Dyslipidaemia was even higher than the increase observed in the use of
Hypertension mechanical prophylaxis in these patients (GCS 45% and PCI
Smoking habit 42%), while the percentage of hospitals not using prophylaxis
ACS in these cases fell to just 6%.
Stable angina
PCI + stent Discussion
Stroke
Mechanical heart valve The aim of SEDAR’s neuroscience team was to gain insight
AF into thromboprophylaxis and the management of antico-
ACS: acute coronary syndrome; AF: atrial fibrillation; DM: dia- agulation and antiplatelet agents in clinical practice in
betes mellitus; PCI: percutaneous coronary intervention. neurosurgical and neurocritical patients by means of a
National survey on thromboprophylaxis and anticoagulant/antiplatelet management 561

Table 3 Management of antiplatelet therapy in neurosurgical patients.

Suspend ASA ASA 100 mg Suspend clopidogrel NA
<3 RF C 29 (79); SS 25 (69) 3 (9); 8 (23) 37 (100); 37 (100) 4 (12); 3 (8)
≥3 RF C 18 (49)* ; SS 14 (38)* 12 (31)* ; 19 (50)* 37 (100); 37 (100) 7 (20); 4 (12)
Coronary stent and sole C 13 (37)* 17 (46)* 37 (100) 6 (17)
antiplatelet agent
Coronary stent C 16 (44)* 20 (53)* 37 (100) 1 (3)
and combination
antiplatelet agent
ASA: acetylsalicylic acid; C: craniotomy; CC: spinal surgery; NA: no answer; RF: risk factors.
Results expressed as number of respondent hospitals (%).
* p < 0.001 with respect to the group with less than 3 risk factors.

nation-wide survey. It is important to note that mechani- consistent with the recommendations of the American Col-
cal prophylaxis is preferred over pharmacologic strategies lege of Chest Physicians in craniotomy patients at high risk
in these patients. We also detected a wide range of clini- for VTE, for example, those undergoing surgery for malig-
cal practices in the different sections of the questionnaire. nant disease. These, in fact, account for the majority of
This difference in approach between hospitals could be such cases.14 There is also evidence of consensus on which
explained by the scant use of specific written protocols; only LMWH to use, this being enoxaparin (used in 78% of hospi-
27% of hospitals had such protocols in place. Differences tals), followed by bemiparin, which is used to a far lesser
were observed in VTE prophylaxis in patients both with and extent. Far less agreement is found on the dosing schedule
without a history of thrombosis, and are evident in both for pharmacologic prophylaxis, although 24 h post-surgery is
the mechanical prophylaxis and pharmacologic strategies the most frequent, and safest, regimen.15,16 It is striking that
used. up to 11% of hospitals give LMWH 12 or 24 h before surgery
Mechanical prophylaxis with CGS is the first-line rec- in patients with no other previous risk factors, when this is
ommendation of National Institute for Health and Clinical even considered an alternative in orthopaedic surgery.11 In
Excellence guidelines,8 and is the most commonly used patients on coumarin derivatives who are given preoperative
mechanical strategy in respondent hospitals (83%). However, LMWH, there is little consensus on when to administer the
evidence to support the effectiveness of this treatment is final preoperative dose of LMWH. Perhaps the safest strat-
weak, mainly due to the quality of existing studies, many of egy, and one used by 51% of hospitals, is to administer it 24 h
which are not double blind. The findings are hard to interpret prior to surgery.5 In patients receiving previous anticoagu-
due to the wide variety of compression methods available, lants due to a high risk for thromboembolism, the strategy
and this is reflected in the heterogeneous nature of the study for restarting the treatment in the postoperative period also
populations.9 A recent multicentre, randomised clinical trial varies greatly. Most (24%) hospitals, however, restart treat-
in 2500 stroke patients was unable to prove the efficacy of ment 24 h post-surgery. Low-dose anticoagulants should be
mechanical methods for preventing VTE,10 although whether administered during the first week post-surgery due to the
or not these findings cannot be extrapolated to surgical risk of bleeding. After this, dosage should be gradually
patients is debatable. In the ninth edition of their guidelines, increased.5 In patients with few risk factors, previously
the American College of Chest Physicians recommend IPC receiving antiplatelet therapy with ASA, most respondent
as first-line mechanical thromboprophylaxis, and specifically hospitals suspended antiplatelet treatment 5 days prior to
advise against the use of GCS in medical patients.11 In a sys- craniotomy. However, it is interesting to note that 9% per-
tematic review of 22 clinical trials on IPC with a total of 2779 form surgery while administering 100 mg oral ASA every 24 h,
patients, this method was associated with a 64% reduction bearing in mind its role as a primary prophylaxis. Differ-
in the risk for VTE,12 while a more recent multicentre trial ences in the management of these patients increase when
also demonstrated its effectiveness in medical patients.13 more risk factors are present. Thus, with 3 or more risk
Correctly applied, i.e., for at least 18 h each day,11 IPC factors, nearly 30% of hospitals perform craniotomy while
in the intra- and immediate postoperative period seems maintaining 100 mg/day of oral ASA. This increases to 47%
to be the norm in slightly over half of respondent hospitals in patients with a coronary stent taking 1 antiplatelet drug,
(56% and 61%, respectively). This is greatly reduced after and to 55% in the case of dual antiplatelet therapy. This
transfer of the patient to the ward. It is interesting to note strategy, however, is still controversial, and only 38% of hos-
that around 25% of respondent hospitals never use IPC. This pitals with neurosurgeons perform craniotomy with ASA in
could be due to the general preference for gradual compres- patients with previous combination antiplatelet treatment.
sion stockings. Nevertheless, some aspects of IPC use are There is a significant difference between hospitals perform-
still unclear; for example, whether different compression ing craniotomy with ASA in the few risk factors/primary
systems are comparable, and how long the therapy should prophylaxis patient group and those that perform this pro-
be applied after surgery. cedure in groups with more risk factors, although the
Most (75%) respondent hospitals used LMWH for phar- percentage of hospitals performing intracranial surgery with
macologic thromboprophylaxis following craniotomy. This is ASA in the primary prophylaxis/few risk factors group is
562 E. Vázquez-Alonso et al.

clinically relevant. Although the decision to proceed must advantages of prothrombin complex in emergency cran-
ultimately be taken in consensus on a case-by-case basis iotomy (possibly more effective, shorter administration time
in high risk patients, weighing cardiovascular risk against with less volume) would probably explain why this therapy
risk of bleeding, the general recommendation is to sus- was the first choice among respondent hospitals.
pend antiplatelet therapy prior to craniotomy.4,17,18 Studies With regard to more specific circumstances, such a TBI
have reported that suspension of antiplatelet therapy with with no previous anticoagulant therapy, mechanical VTE pro-
ASA in coronary patients increases the risk of cardiovascu- phylaxis is usually used. It is important to note, however,
lar complications three-fold, above all between 7 and 14 that 24% of respondent hospitals do not administer any kind
days after suspension.19---21 The same is true of patients with of prophylaxis, thus potentially, and unjustifiably, placing
cerebrovascular and peripheral artery disease.22,23 this population at high risk of VTE. LMWH prophylaxis is
In the case of clopidogrel, studies have reported an used far more often in patients previously treated with anti-
increase in cardiovascular complications and mortality at coagulant therapy (52%) than in patients with no previous
3 months post-surgery following suspension of this drug anticoagulant treatment (35%). This highlights the risk of
in patients with acute coronary syndrome.24 However, a thrombosis in this patient population as a defining factor in
recent clinical trial in non-cardiac surgery (orthopaedic, hospital treatment.
abdominal and urological) patients found no difference One known limitation of this type of survey lies in the
in thrombotic and bleeding events between the group response rate. In our case, this was 50.7%, slightly lower
receiving ASA and placebo.25 Furthermore, a recent retro- than that of another survey evaluating the same popu-
spective cohort study in 41,989 patients with coronary stents lation (anaesthesia in patients undergoing posterior fossa
showed that unscheduled hospital admission is the single craniotomy),33 but higher than a survey on subarachnoid
most important determining factor for serious adverse car- haemorrhage due to spontaneous aneurysmal rupture.34
diac events. This is followed by clinical conditions such as In conclusion, we believe that the results of the survey
recent myocardial infarction, heart failure, or a high score describe the most common approach to thromboprophy-
in the revised cardiac risk index.26 However, the type of laxis and the management of anticoagulants and antiplatelet
stent implanted, or the time from stent to surgery was therapy in neurosurgical and neurocritical patients in Spain.
not associated with an increase in adverse cardiac events. An analysis of the results will form the basis for proposals for
More importantly for neurosurgical patient management, more standardised treatment regimens, thus reducing clini-
however, the study found no association between suspen- cal variability. Anaesthesiologists must be directly involved
sion of antiplatelet treatment and onset of serious cardiac in bringing about this change.
events.
Renal replacement therapy has been used in patients at
high risk for thrombosis in whom antiplatelet therapy has Funding
had to be temporarily suspended due to risk of bleeding. This
basically involves the use of short-acting antiplatelet drugs No external funding has been received for this project,
instead of the usual ASA and clopidogrel. Nonsteroidal anti- which has been carried out with the help of the members
inflammatory drugs or glycoprotein IIb/IIIa inhibitors27---29 of SEDAR’s neuroscience team.
have been used, albeit with little clinical evidence. Indeed,
flurbiprofen has occasionally been used as bridging therapy
in patients scheduled for craniotomy with single or combi- Conflict of interests
nation antiplatelet therapy in only 1 respondent hospital, as
shown in the survey results. Few studies have investigated The authors declare they have no conflicts of interest.
the use of glycoprotein IIb/IIIa inhibitors as bridging ther-
apy. Promising results, however, have been reported with
tirofiban in non-cardiac surgery, although these studies did Acknowledgements
not include craniotomy.30,31
Management of antiplatelet therapy in spinal surgery We would like to thank all the anaesthesiologists from
was similar to craniotomy, with 50% of hospitals performing Spanish hospitals providing neurosurgery services and who
surgery with ASA in patients with risk factors. LMWHs are participated in this survey.
given as thromboprophylaxis in these cases, in both at-risk
and no-risk patients. This strategy is in line with the recom-
mendations of the American College of Chest Physicians.14 Appendix A. Supplementary data
Another important aspect of thromboprophylaxis in neuro-
surgical patients is that thromboprophylaxis in minimally Supplementary data associated with this article can be
invasive surgery is largely similar (in 70% of hospitals) to found, in the online version, at doi:10.1016/j.redare.
the regimen used in patients scheduled for craniotomy. In 2015.08.003.
emergency craniotomy in patients on anticoagulation ther-
apy with coumarin derivatives, 80% of respondent hospitals
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