Anaesthesia 2013, 68, 1274–1287
Training guide [3] and in the Association of Paediatric Anaesthetists of Great Britain and Ireland’s 2008 guidelines [4]. In Reading, since 2004, we have used a PONV protocol based on Apfel et al.’s simplified scoring system of four factors (female sex, history of motion sickness or PONV, non-smoking and use of postoperative opioids) [5]; patients with any one of these are prescribed prophylactic antiemetics if they undergo general anaesthesia, and those with any three receive total intravenous anaesthesia (TIVA), rather than volatile agents. Dexamethasone has been the inexpensive first-line choice, partly because it enhances the patients’ mood, but also because it is a superior antiemetic to propofol TIVA in the first 24 hours postoperatively [6]. The combination of dexamethasone and ondansetron remains a popular choice for female non-smokers. Admissions for PONV after day-case surgery are rare. We have not seen gastric ulceration or psychiatric disturbance. A single dose of dexamethasone is administered to diabetics with prolonged PONV that interferes with oral intake of food, without disturbance of their blood sugar control. On visiting Kehlet’s group in Copenhagen, we learned that widespread use of dexamethasone was not associated with any increase in postoperative infection in arthroplasty patients. Neither editorial mentioned that use of dexamethasone as a prophylactic antiemetic lies outside the
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manufacturer’s marketing authorisation. The General Medical Council advises doctors to use drugs that are licensed for a particular indication in preference to those that lack a marketing authorisation for that purpose. In advocating elective treatment with a drug that is ‘offlabel’, specific informed consent should be sought from the patient pre-operatively [7]. The Royal College of Anaesthetists helpfully provide written information to this end, that can be provided for patients at pre-operative assessment clinics or by direction to the website [8].
5. Apfel CC, Laara E, Koivuranta M, Griem CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centres. Anesthesiology 1999; 91: 693–700. 6. Apfel CC, Korttila A, Abdula M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. New England Journal of Medicine 2004; 350: 2441–51. 7. Mackenzie JW. Whose licence is it anyway? Anaesthesia News 2010; 271: 17–8. 8. The Royal College of Anaesthetists. Risks associated with your anaesthetic. Section 1: feeling sick. 2013. http://www. rcoa.ac.uk/system/files/PI-Risk1_3.pdf (accessed 09/09/2013).
J. Mackenzie Royal Berkshire Hospital, Reading, UK Email: [email protected]
Regional anaesthesia and patients with abnormalities of coagulation
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
My congratulations to the Working Party for producing user-friendly guidance on the management of regional anaesthesia in patients with abnormalities of coagulation [1]. I wonder if the authors could clarify the recommendation that regional anaesthesia should not be performed for five days following the administration of ticagrelor. As a reversible, direct acting platelet ADP P2Y12 receptor with a half-life of 812 hours, following 48 hours (approximately five plasma half-lives) from last admission, the inhibitory platelet effect will almost completely have reversed. I am aware of anaesthetic departments in my region currently using two days as an acceptable time after drug administration to perform regional anaesthesia.
References 1. Kakodkar PS. Routine use of dexamethasone for postoperative nausea and vomiting; the case for. Anaesthesia 2013; 68: 889–891. 2. Bartlett R, Hartle AJ. Routine use of dexamethasone for postoperative nausea and vomiting; the case against. Anaesthesia 2013; 68: 892–96. 3. The Royal College of Anaesthetists. Basic Level training guide, 2012. https://www.rcoa.ac.uk/system/files/ TRG-CCT-AnnexB_1.pdf (accessed 09/ 09/2013). 4. Association of Paediatric Anaesthetists of Great Britain and Ireland. Guidelines on the prevention of post-operative vomiting in children, Spring, 2009. http://www.apagbi.org.uk/sites/defau lt/files/APA_Guidelines_on_the_Preven tion_of_Postoperative_Vomiting_in_Chil dren.pdf (accessed 09/09/2013).
doi:10.1111/anae.12513
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2013, 68, 1274–1287
T. Collyer Harrogate District Foundation Hospital Harrogate, UK Email: [email protected] No external funding and no competing interests declared.
Reference 1. Harrop-Griffiths W, Cook TM, Gill H, et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72. doi:10.1111/anae.12508
A reply We thank Dr Collyer for his response to the guidelines [1]. The advice we have given, that clinicians should wait for five days after the last dose of ticagrelor before performing a block, is based on existing guidance and a published study. The guidance is that from the European Society of Anaesthesiology [2], although the evidence supporting the choice of five days is identified as being ‘expert opinion’ (Level III, Class C). The study is one that compared the antiplatelet effects of clopidogrel and ticagrelor
[3]. At 48 hours after cessation, there was significantly impaired platelet activity with both drugs. Normal activity was achieved five days after cessation of ticagrelor and seven days after cessation of clopidogrel. Further, the manufacturer’s Summary of Produce Characteristics recommends cessation of ticagrelor for seven days before surgery [4]. Give this information, we thought it unwise to recommend a shorter cessation period. However, if an assessment of the risks and benefits for an individual patient indicates that he/she may benefit from regional anaesthesia within this five-day period, we see no reason that a block should not be performed provided the patient provides consent. We were careful to say in the opening paragraphs of the guidance document that: “This guidance must be interpreted and used after consideration of an individual patient’s circumstances. None of the advice in this guidance should be taken as being prohibitive or indicative”.
T. Cook Association of Anaesthetists of Great Britain & Ireland Obstetric Anaesthetists’ Association and Regional Anaesthesia UK Working Party Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia website: www.anaesthesiacorrespondence.com.
References 1. Harrop-Griffiths W, Cook TM, Gill H, et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72. 2. Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. European Journal of Anaesthesiology 2010; 27: 999–1015. 3. Gurbel PA, Bliden KP, Butler K, et al. Randomized double-blind assessment of the onset and offset of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease. Circulation 2009; 120: 2577– 85. 4. Ticagrelor Summary of Produce Characteristics. http://www.medicines.org.uk/ emc/medicine/23935/spc (accessed 15/10/13). doi:10.1111/anae.12507
M. Makris W. Harrop-Griffiths
Visit the Anaesthesia Correspondence website at http://www.anaesthesiacorrespondence.com and comment on any article or letter in this issue of the Journal.
© 2013 The Association of Anaesthetists of Great Britain and Ireland
1287
Training guide [3] and in the Association of Paediatric Anaesthetists of Great Britain and Ireland’s 2008 guidelines [4]. In Reading, since 2004, we have used a PONV protocol based on Apfel et al.’s simplified scoring system of four factors (female sex, history of motion sickness or PONV, non-smoking and use of postoperative opioids) [5]; patients with any one of these are prescribed prophylactic antiemetics if they undergo general anaesthesia, and those with any three receive total intravenous anaesthesia (TIVA), rather than volatile agents. Dexamethasone has been the inexpensive first-line choice, partly because it enhances the patients’ mood, but also because it is a superior antiemetic to propofol TIVA in the first 24 hours postoperatively [6]. The combination of dexamethasone and ondansetron remains a popular choice for female non-smokers. Admissions for PONV after day-case surgery are rare. We have not seen gastric ulceration or psychiatric disturbance. A single dose of dexamethasone is administered to diabetics with prolonged PONV that interferes with oral intake of food, without disturbance of their blood sugar control. On visiting Kehlet’s group in Copenhagen, we learned that widespread use of dexamethasone was not associated with any increase in postoperative infection in arthroplasty patients. Neither editorial mentioned that use of dexamethasone as a prophylactic antiemetic lies outside the
1286
Correspondence
manufacturer’s marketing authorisation. The General Medical Council advises doctors to use drugs that are licensed for a particular indication in preference to those that lack a marketing authorisation for that purpose. In advocating elective treatment with a drug that is ‘offlabel’, specific informed consent should be sought from the patient pre-operatively [7]. The Royal College of Anaesthetists helpfully provide written information to this end, that can be provided for patients at pre-operative assessment clinics or by direction to the website [8].
5. Apfel CC, Laara E, Koivuranta M, Griem CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centres. Anesthesiology 1999; 91: 693–700. 6. Apfel CC, Korttila A, Abdula M, et al. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. New England Journal of Medicine 2004; 350: 2441–51. 7. Mackenzie JW. Whose licence is it anyway? Anaesthesia News 2010; 271: 17–8. 8. The Royal College of Anaesthetists. Risks associated with your anaesthetic. Section 1: feeling sick. 2013. http://www. rcoa.ac.uk/system/files/PI-Risk1_3.pdf (accessed 09/09/2013).
J. Mackenzie Royal Berkshire Hospital, Reading, UK Email: [email protected]
Regional anaesthesia and patients with abnormalities of coagulation
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
My congratulations to the Working Party for producing user-friendly guidance on the management of regional anaesthesia in patients with abnormalities of coagulation [1]. I wonder if the authors could clarify the recommendation that regional anaesthesia should not be performed for five days following the administration of ticagrelor. As a reversible, direct acting platelet ADP P2Y12 receptor with a half-life of 812 hours, following 48 hours (approximately five plasma half-lives) from last admission, the inhibitory platelet effect will almost completely have reversed. I am aware of anaesthetic departments in my region currently using two days as an acceptable time after drug administration to perform regional anaesthesia.
References 1. Kakodkar PS. Routine use of dexamethasone for postoperative nausea and vomiting; the case for. Anaesthesia 2013; 68: 889–891. 2. Bartlett R, Hartle AJ. Routine use of dexamethasone for postoperative nausea and vomiting; the case against. Anaesthesia 2013; 68: 892–96. 3. The Royal College of Anaesthetists. Basic Level training guide, 2012. https://www.rcoa.ac.uk/system/files/ TRG-CCT-AnnexB_1.pdf (accessed 09/ 09/2013). 4. Association of Paediatric Anaesthetists of Great Britain and Ireland. Guidelines on the prevention of post-operative vomiting in children, Spring, 2009. http://www.apagbi.org.uk/sites/defau lt/files/APA_Guidelines_on_the_Preven tion_of_Postoperative_Vomiting_in_Chil dren.pdf (accessed 09/09/2013).
doi:10.1111/anae.12513
© 2013 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2013, 68, 1274–1287
T. Collyer Harrogate District Foundation Hospital Harrogate, UK Email: [email protected] No external funding and no competing interests declared.
Reference 1. Harrop-Griffiths W, Cook TM, Gill H, et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72. doi:10.1111/anae.12508
A reply We thank Dr Collyer for his response to the guidelines [1]. The advice we have given, that clinicians should wait for five days after the last dose of ticagrelor before performing a block, is based on existing guidance and a published study. The guidance is that from the European Society of Anaesthesiology [2], although the evidence supporting the choice of five days is identified as being ‘expert opinion’ (Level III, Class C). The study is one that compared the antiplatelet effects of clopidogrel and ticagrelor
[3]. At 48 hours after cessation, there was significantly impaired platelet activity with both drugs. Normal activity was achieved five days after cessation of ticagrelor and seven days after cessation of clopidogrel. Further, the manufacturer’s Summary of Produce Characteristics recommends cessation of ticagrelor for seven days before surgery [4]. Give this information, we thought it unwise to recommend a shorter cessation period. However, if an assessment of the risks and benefits for an individual patient indicates that he/she may benefit from regional anaesthesia within this five-day period, we see no reason that a block should not be performed provided the patient provides consent. We were careful to say in the opening paragraphs of the guidance document that: “This guidance must be interpreted and used after consideration of an individual patient’s circumstances. None of the advice in this guidance should be taken as being prohibitive or indicative”.
T. Cook Association of Anaesthetists of Great Britain & Ireland Obstetric Anaesthetists’ Association and Regional Anaesthesia UK Working Party Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia website: www.anaesthesiacorrespondence.com.
References 1. Harrop-Griffiths W, Cook TM, Gill H, et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72. 2. Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. European Journal of Anaesthesiology 2010; 27: 999–1015. 3. Gurbel PA, Bliden KP, Butler K, et al. Randomized double-blind assessment of the onset and offset of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease. Circulation 2009; 120: 2577– 85. 4. Ticagrelor Summary of Produce Characteristics. http://www.medicines.org.uk/ emc/medicine/23935/spc (accessed 15/10/13). doi:10.1111/anae.12507
M. Makris W. Harrop-Griffiths
Visit the Anaesthesia Correspondence website at http://www.anaesthesiacorrespondence.com and comment on any article or letter in this issue of the Journal.
© 2013 The Association of Anaesthetists of Great Britain and Ireland
1287
