Risk of Hemorrhage during Needle-Based Ophthalmic Regional Anesthesia in Patients Taking Antithrombotics: A Systematic Review.

Augusto Takaschima,Graziela De Luca Canto,Luis André Mezzomo,Patricia Marchioro,André L Porporatti,Thiago M Sakae,Demetrios G Vavvas

doi:10.1371/journal.pone.0147227

Abstract

BackgroundPatients undergoing ophthalmic surgery are usually elderly and, due to systemic disease, may be on long-term therapy, such as antithrombotic agents. Rates of hemorrhagic complications associated with invasive procedures may be increased by the use of anticoagulants and antiplatelet agents.ObjectiveTo compare the incidence of hemorrhagic complications in patients undergoing needle-based ophthalmic regional anesthesia between patients on antithrombotic therapy and those not on such therapy.MethodsA systematic review was conducted by two independent reviewers based on searches of Cochrane, LILACS, PubMed, Scopus, Web of Science, and the “gray” literature (Google Scholar). The end search date was May 8, 2015, across all databases.ResultsFive studies met the eligibility criteria. In three studies, individual risk of bias was low, and in two of them, moderate. In all studies, no differences regarding mild to moderate incidence of hemorrhagic complications were found between patients using antithrombotics (aspirin, clopidogrel, and warfarin) and those not using them. Rates of severe hemorrhagic complication were very low (0.04%) in both groups, supporting the safety of needle blocks, even in patients using antithrombotics. High heterogeneity across studies prevented meta-analysis. Limitations to these results include low statistical power in three experimental studies and a large 95% confidence interval in the two retrospective cohorts.ConclusionIn this review, none of the selected studies showed significant bleeding related to needle-based ophthalmic regional anesthesia in association with the use of aspirin, clopidogrel, or vitamin K inhibitors. Since the available data is not powerful enough to provide a reliable evaluation of the true effect of antithrombotics in this setting, new studies to address these limitations are necessary.

Highlights

Patients undergoing ophthalmic surgery are usually elderly and often undergo long-term therapy for systemic diseases, including cardiac problems [1,2,3,4]
No differences regarding mild to moderate incidence of hemorrhagic complications were found between patients using antithrombotics and those not using them
In a retrospective cohort study, Kallio et al [16] evaluated hemorrhagic complications associated with retrobulbar or peribulbar anesthesia in 1,383 patients using or not using antithrombotics who were scheduled for ophthalmic surgeries

Summary

Introduction

Patients undergoing ophthalmic surgery are usually elderly and often undergo long-term therapy for systemic diseases, including cardiac problems [1,2,3,4]. Some studies [2, 5] have reported a higher incidence of subconjunctival hemorrhage in patients using antithrombotics when undergoing ophthalmic regional anesthesia Reduction of this risk of hemorrhage can sometimes be achieved with topical anesthesia [6], for some ocular procedures, this technique might not be an option [7]. Considering that it is rare for general anesthesia to be used during ophthalmic surgery [1], many patients on antithrombotics who have ophthalmic surgeries undergo needle-based regional anesthesia [7]. Patients undergoing ophthalmic surgery are usually elderly and, due to systemic disease, may be on long-term therapy, such as antithrombotic agents. Rates of hemorrhagic complications associated with invasive procedures may be increased by the use of anticoagulants and antiplatelet agents

Results

Discussion

Conclusion