What are the anesthesia recommendations for a patient with Antiphospholipid Syndrome (APS)?

Anesthesia Management for Patients with Antiphospholipid Syndrome (APS)

For patients with Antiphospholipid Syndrome (APS) requiring anesthesia, vitamin K antagonists (VKAs) with a target INR of 2.5 should be used over direct oral anticoagulants (DOACs), with careful perioperative anticoagulation management to balance thrombotic and bleeding risks. 1

Preoperative Considerations

Anticoagulation Management

• APS patients are typically on long-term anticoagulation therapy, most commonly with vitamin K antagonists (VKAs)
• For elective procedures:
  • Discuss anticoagulation management with the patient's hematologist/cardiologist 1
  • VKAs should be discontinued 5 days before surgery with INR monitoring
  • Consider bridging therapy with therapeutic-dose LMWH for high thrombotic risk patients
  • Stop LMWH 24 hours before surgery

Thrombotic Risk Assessment

• APS patients have significantly increased baseline thrombotic risk
• Higher risk factors include:
  • Previous arterial thrombosis
  • Triple antibody positivity
  • History of recurrent thrombosis
  • Concomitant autoimmune disorders

Bleeding Risk Assessment

• Evaluate for thrombocytopenia (common in APS)
• Check coagulation studies (PT/INR, aPTT)
  • Note: Lupus anticoagulant can artificially prolong aPTT without affecting actual coagulation 1
• Review medication history for antiplatelet agents

Regional vs. General Anesthesia Considerations

Regional Anesthesia

• Neuraxial anesthesia (epidural/spinal):

  • Contraindicated if patient is anticoagulated (INR >1.4) 1
  • Requires discontinuation of anticoagulation with appropriate washout periods:
    • VKAs: 5 days with INR normalization
    • LMWH: 24 hours (therapeutic dose) or 12 hours (prophylactic dose)
  • Catheter manipulation and removal carry similar risks to insertion 1

• Peripheral nerve blocks:

  • Low bleeding risk blocks (superficial, compressible areas) may be performed if benefit outweighs risk
  • High bleeding risk blocks (deep, non-compressible) are contraindicated in anticoagulated patients 1
  • Ultrasound guidance recommended to reduce vascular puncture risk

General Anesthesia

• Often preferred for APS patients on anticoagulation
• Advantages:
  • Avoids neuraxial bleeding complications
  • Allows better hemodynamic control
  • Appropriate for emergency procedures when anticoagulation cannot be reversed

Intraoperative Management

Monitoring

• Standard ASA monitoring plus:
  • Consider arterial line for hemodynamic monitoring and frequent blood sampling
  • Temperature monitoring (avoid hypothermia which worsens coagulopathy)

Hemodynamic Management

• Maintain normotension and adequate tissue perfusion
• Avoid prolonged hypotension which may increase thrombotic risk
• Ensure adequate hydration to prevent stasis

Thromboprophylaxis

• Early mobilization
• Mechanical prophylaxis (sequential compression devices)
• Consider intraoperative heparin if prolonged procedure and high thrombotic risk

Postoperative Management

Anticoagulation Resumption

• Resume anticoagulation as early as possible based on bleeding risk:
  • For low bleeding risk: Resume within 24 hours
  • For high bleeding risk: Resume within 48-72 hours 1
• If both antiplatelet agents and anticoagulants are used, resume the anticoagulant first

Monitoring for Complications

• Vigilant monitoring for both thrombotic and bleeding complications
• Early signs of catastrophic APS: Fever, organ dysfunction, thrombocytopenia
• Consider ICU monitoring for high-risk patients

Special Considerations

Emergency Surgery

• If urgent surgery is required while on anticoagulation:
  • Consider reversal agents for VKAs if high bleeding risk
  • Platelet transfusion may be needed for patients on antiplatelet therapy 1
  • Surgery should be performed in facilities with 24/7 access to hematology consultation

Catastrophic APS Prevention

• Maintain strict aseptic technique
• Avoid triggers (infection, trauma, anticoagulation withdrawal)
• Early recognition and aggressive management of complications

Common Pitfalls and Caveats

1. Do not rely on aPTT for monitoring anticoagulation in APS patients as lupus anticoagulant can artificially prolong aPTT 2

2. Avoid DOACs as primary anticoagulation in APS patients - evidence suggests inferior protection against thrombotic events compared to VKAs 1

3. Never abruptly discontinue anticoagulation without bridging strategy in high-risk APS patients

4. Do not use NSAIDs in patients on dual antiplatelet therapy due to increased bleeding risk 1

5. Recognize that APS patients remain at high thrombotic risk even when anticoagulated - maintain vigilance throughout perioperative period 3