ADD-ONS / MEDICATION
Lumbar puncture and antithrombotic therapy
Created 07/02/2022, last revision 25/05/2023
- lumbar puncture (LP), also known as a spinal tap, is an important and commonly performed invasive procedure to obtain cerebrospinal fluid (CSF) for diagnostic testing
- the procedure is associated with some risk of spinal bleeding (most often epidural hematoma)
- high-risk conditions include:
- coagulopathies (including pharmacologically induced)
- advanced age
- multiple puncture attempts
- spinal pathology
- the potential benefit of the procedure must outweigh the risk of bleeding
- avoid repeated puncture attempts in high-risk patients
- spinal hematoma should be suspected in the case of sudden sensorimotor and/or sphincter deficits or severe low back pain after puncture ⇒ perform MRI immediately and consult a neurosurgeon ( after > 8h the prognosis is already unfavorable despite successful surgery!) [Herlocker, 2010]
- on the other hand, periprocedural discontinuation of antithrombotic medication is associated with an increased risk of thromboembolism
- aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes (Burger, 2005)
- the potential benefit of lumbar puncture must always outweigh the risk of thrombosis
- bridging therapy may be required in high-risk patients
- consultation with the specialist who ordered the antithrombotic therapy and a hematologist is recommended
Coagulopathies
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Antiplatelet therapy
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Urgent reversal of antiplatelet drugs effect
- prophylactic reversal of antiplatelet therapy is not a routine procedure and rather should be avoided (risk of thrombosis)
- 2-3 units of platelets may be considered (provides functional, circulating platelets); consult a hematologist
- studies have shown mixed results regarding the benefit of this practice; there is no standard dose and no effect was shown in the PATCH trial
- desmopressin (ddAVP) OCTOSTIM – 0,3 ug/kg +100 mL of NS, infusion over 15-30 min
- benefit unproven when used before lumbar puncture, data only available for general surgery (reduced need for transfusion was reported) (Desborough, 2016)
Anticoagulant therapy and thrombolysis
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LMWH bridging
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