Neuroaxial anesthesia and anticoagulation

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militarymd

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Yesterday, I had a sickly, frail, little old lady scheduled for an amputation. She has a significant cardiac history which includes Atrial fibrillation and anticoagulation with coumadin to an INR of 2.5 ...PT of 24 seconds.

She stopped her coumadin 3 days ago, and there is no repeat lab today....Would anyone put a spinal in her?
 
militarymd said:
Yesterday, I had a sickly, frail, little old lady scheduled for an amputation. She has a significant cardiac history which includes Atrial fibrillation and anticoagulation with coumadin to an INR of 2.5 ...PT of 24 seconds.

She stopped her coumadin 3 days ago, and there is no repeat lab today....Would anyone put a spinal in her?
Click to expand...

nope.
 
militarymd said:
Yesterday, I had a sickly, frail, little old lady scheduled for an amputation. She has a significant cardiac history which includes Atrial fibrillation and anticoagulation with coumadin to an INR of 2.5 ...PT of 24 seconds.

She stopped her coumadin 3 days ago, and there is no repeat lab today....Would anyone put a spinal in her?
Click to expand...


no
 
VentdependenT said:
Are peripheral nerve blocks contraidicated in this situation as well?

Can they go to surgery with an INR of 2.5 anyways?
Click to expand...


sorry about being unclear. Her INR was 2.5 three days ago, when she stopped her coumadin. No labs on the day of surgery. but off coumadin for 3 days.

I explained to her about why it is not a good idea to have a spinal (her cardiologist told her that is what she needed to have.....again).....an associate of mine proceeds and performs a spinal .....after I told her that the asra concensus statement recommends a minimum of 4 to 5 days. 😱
 
militarymd said:
sorry about being unclear. Her INR was 2.5 three days ago, when she stopped her coumadin. No labs on the day of surgery. but off coumadin for 3 days.

I explained to her about why it is not a good idea to have a spinal (her cardiologist told her that is what she needed to have.....again).....an associate of mine proceeds and performs a spinal .....after I told her that the asra concensus statement recommends a minimum of 4 to 5 days. 😱
Click to expand...

Did she develop a hematoma?
 
militarymd said:
sorry about being unclear. Her INR was 2.5 three days ago, when she stopped her coumadin. No labs on the day of surgery. but off coumadin for 3 days.

I explained to her about why it is not a good idea to have a spinal (her cardiologist told her that is what she needed to have.....again).....an associate of mine proceeds and performs a spinal .....after I told her that the asra concensus statement recommends a minimum of 4 to 5 days. 😱
Click to expand...
Why not repeat the coags first? It's not like those labs take a long time to run.

And what is it with your cardiologists prescribing anesthetics? Haven't you had "the talk" with them yet? 😉

Oh, as for the original question - not just no, but hell no, without repeat labs, and screw the cardiologist. Either that or you should start doing cardiac caths and stents.
 
jwk said:
Why not repeat the coags first? It's not like those labs take a long time to run.

And what is it with your cardiologists prescribing anesthetics? Haven't you had "the talk" with them yet? 😉

Oh, as for the original question - not just no, but hell no, without repeat labs, and screw the cardiologist. Either that or you should start doing cardiac caths and stents.
Click to expand...


I was going to put her to sleep.....then the late doc shows up.

I don't know where this cardiologist is....just somewhere out in the community.
 
militarymd said:
I was going to put her to sleep.....then the late doc shows up.

I don't know where this cardiologist is....just somewhere out in the community.
Click to expand...

As you know just as good as I do, Military, putting her to sleep was the safer play. Screw the litiginous part (if she develops a hematoma your partner has no defense). Thats blatent disregard for the patient's well being. I wouldnt've put a spinal in even if the case was an emergency. And this wasnt an emergency.

The issue of lack of consensus in a group has come up before with your group. My opinion, again, is you guys need to be united in opinion. Your opinion about this case was the correct one (again). If your partners are unable to see the light (global picture light, united light), then its time for a "come to Jesus" meeting with your partners.

A group that functions as individuals and not like a cohesive group has no integrity and will eventually dissolve.
 
VentdependenT said:
Are peripheral nerve blocks contraidicated in this situation as well?

Can they go to surgery with an INR of 2.5 anyways?
Click to expand...

You don't wanna stick a needle anywhere if the patient's coags are questionable, so yes, peripheral nerve blocks are contraindicated.
An open surgical field where you can identify bleeders is different than probing around somewhere with a needle, so some surgeons would probably go ahead. But its taking a chance, and interventions should be taken intraoperatively (at least), like new labs to see where the patients coags are, FFP, etc.
If the surgeon insisted on doing the case, I wouldve put her to sleep and sent off new coags.
 
While we're on the subject lemme know if this sounds reasonable for anticoags and insertion of neuraxial epidurals:

Sub Q heparin for thromboprophylaxis:
may start 1 hr before subq OR 4 hrs after last subq
spinal: go for it?

IV heparin:
24 hrs off before starting

LMWH sub Q prophyl:
?
insert after 13 hours off OR 12 hours before....sounds goofy

LMWH 1mg/kg:
24 hours off.

Coumadin:
5 days with repeat coags

Aspirin, clopridigel, plavix:
Ok if not giving with any o' the above.

Correct me freely porfavor.
 
VentdependenT said:
While we're on the subject lemme know if this sounds reasonable for anticoags and insertion of neuraxial epidurals:

Sub Q heparin for thromboprophylaxis:
may start 1 hr before subq OR 4 hrs after last subq
spinal: go for it?

IV heparin:
24 hrs off before starting

LMWH sub Q prophyl:
?
insert after 13 hours off OR 12 hours before....sounds goofy

LMWH 1mg/kg:
24 hours off.

Coumadin:
5 days with repeat coags

Aspirin, clopridigel, plavix:
Ok if not giving with any o' the above.

Correct me freely porfavor.
Click to expand...

What the ****?
 
VentdependenT said:
While we're on the subject lemme know if this sounds reasonable for anticoags and insertion of neuraxial epidurals:

Sub Q heparin for thromboprophylaxis:
may start 1 hr before subq OR 4 hrs after last subq
spinal: go for it?

IV heparin:
24 hrs off before starting

LMWH sub Q prophyl:
?
insert after 13 hours off OR 12 hours before....sounds goofy

LMWH 1mg/kg:
24 hours off.

Coumadin:
5 days with repeat coags

Aspirin, clopridigel, plavix:
Ok if not giving with any o' the above.

Correct me freely porfavor.
Click to expand...

These are very good questions, Vent. I'll give you my expert :laugh: opinion.

Subclinical coagulopathies got alotta press in the anesthesia literature a year or so after the low molecular weight heparins came out. What I mean by subclinical is you get the coags and they're normal, but enough medicine was still present to cause some epidural hematomas, so a warning letter was issued.
I"ll do regional if the last LMWH dose was 12 hours or greater ago.

Clopidogrel (Plavix) acts by irreversibly affecting the platelet ADP receptor, with a half life of 7 days, but normal platelet aggregation returns in about 5 days, so I use 5 days as my cutoff for this drug, since there have been reports of hematomas if you do regional before that.

SQ heparin is kinda tricky since the absorption is so variable. I use 12 hours for the cutoff here.

IV heparins half life is short, hence the infusion required. Half life around 90 minutes. 6-8 hours off IV heparin and you're probably golden, but I'll check a PTT before.

5 days off coumadin and you're probably alright. Best to check a PT before anyway. Sometimes I order one, sometimes I dont.

Aspirin doesnt bother me.

I'm comfortable putting in a spinal or epidural for a case that requires heparinization intraop, like a fem pop. Prefer a spinal since you dont have to worry about waiting a while to pull the epidural after the case is over.

Just my personal comfort levels.
 
OK, so surgeon wants to do the case as soon as possible. Pt shows up at the OR door. Park her in holding area and type and cross for 2 units of FFP stat. Draw stat PT and INR. Know results of PT and INR prior to proceeding to OR. You will be doing GA on this pt despite what PT and INR results are. Give her vit.K 10mgs IM to ward off evils. Don't bother calling the cardiologist b/c he ain't in hospital and all you'll get is his answering service, wasting your precious time. Tell pt. spinal ain't right for her at this time because her blood is too thin( you're in Alabama and there aren't a lot of rocket scientists there). Let her know that you may give her some blood products that will counteract that thinned blood of hers because you don't want her to bleed too much during and after surgery. She'll appreciate you for telling her that. Smile and tell surgeon what you're doing and that shortly you will be going back to OR. The worst problem here is the lack of communication b/w you and you partners, setting you guys up for all sorts of legal ramifications that are not in your favor. IF you told her no spinal until 5 days off coumadin, your colleague needs to abide by that-- it's called UNITY! I can assure you that you are advertising for docs to work at your hospital-- I would run from a group like yours.... Warmest regards, ---Zippy
 
It is all in the ASRA concensus statement
 
ASRA, MASRA, BASRA; the pt., the lawyers and the surgeon could give a jodie fook. UNITY is all about common sense-- you ain't goin' to learn that in a book or your yearly ASA conventions. ---Zippy
 
zippy2u said:
OK, so surgeon wants to do the case as soon as possible. Pt shows up at the OR door. Park her in holding area and type and cross for 2 units of FFP stat. Draw stat PT and INR. Know results of PT and INR prior to proceeding to OR. You will be doing GA on this pt despite what PT and INR results are. Give her vit.K 10mgs IM to ward off evils. Don't bother calling the cardiologist b/c he ain't in hospital and all you'll get is his answering service, wasting your precious time. Tell pt. spinal ain't right for her at this time because her blood is too thin( you're in Alabama and there aren't a lot of rocket scientists there). Let her know that you may give her some blood products that will counteract that thinned blood of hers because you don't want her to bleed too much during and after surgery. She'll appreciate you for telling her that. Smile and tell surgeon what you're doing and that shortly you will be going back to OR. The worst problem here is the lack of communication b/w you and you partners, setting you guys up for all sorts of legal ramifications that are not in your favor. IF you told her no spinal until 5 days off coumadin, your colleague needs to abide by that-- it's called UNITY! I can assure you that you are advertising for docs to work at your hospital-- I would run from a group like yours.... Warmest regards, ---Zippy
Click to expand...

Actually we have a lot of rocket scientists here....more than most places in the nation.

I can't help it if I have people around me with poor judgement, and I'm working to bring folks here to replace the lame and disabled.
 
zippy2u said:
ASRA, MASRA, BASRA; the pt., the lawyers and the surgeon could give a jodie fook. UNITY is all about common sense-- you ain't goin' to learn that in a book or your yearly ASA conventions. ---Zippy
Click to expand...


Concensus statements from national society equals what lawyers look to.....ASRA = UNITY
 
zippy2u said:
OK, so surgeon wants to do the case as soon as possible. Pt shows up at the OR door. Park her in holding area and type and cross for 2 units of FFP stat. Draw stat PT and INR. Know results of PT and INR prior to proceeding to OR. You will be doing GA on this pt despite what PT and INR results are. Give her vit.K 10mgs IM to ward off evils. Don't bother calling the cardiologist b/c he ain't in hospital and all you'll get is his answering service, wasting your precious time. Tell pt. spinal ain't right for her at this time because her blood is too thin( you're in Alabama and there aren't a lot of rocket scientists there). Let her know that you may give her some blood products that will counteract that thinned blood of hers because you don't want her to bleed too much during and after surgery. She'll appreciate you for telling her that. Smile and tell surgeon what you're doing and that shortly you will be going back to OR. The worst problem here is the lack of communication b/w you and you partners, setting you guys up for all sorts of legal ramifications that are not in your favor. IF you told her no spinal until 5 days off coumadin, your colleague needs to abide by that-- it's called UNITY! I can assure you that you are advertising for docs to work at your hospital-- I would run from a group like yours.... Warmest regards, ---Zippy
Click to expand...

I wouldn't type X squat....patient has been off coumadin for 3 days....You don't need blood products for an amputation.....

Blood not thick enough for spinal, but FFP and vit K for a BKA?????
 
militarymd said:
Concensus statements from national society equals what lawyers look to.....ASRA = UNITY
Click to expand...

I think you missed the point that I made and that Zippy made, Dude. Nobodys blaming you. Just pointing out that a group is like a marriage and undermining each other leads to its demise.
 
zippy2u said:
ASRA, MASRA, BASRA; the pt., the lawyers and the surgeon could give a jodie fook. UNITY is all about common sense-- you ain't goin' to learn that in a book or your yearly ASA conventions. ---Zippy
Click to expand...

👍
 
militarymd said:
I wouldn't type X squat....patient has been off coumadin for 3 days....You don't need blood products for an amputation.....

Blood not thick enough for spinal, but FFP and vit K for a BKA?????
Click to expand...

I dont know about the vitamin K (takes a long time, multiple doses), but why wouldnt you wanna give FFP if her INR is still off?
 
jetproppilot said:
I dont know about the vitamin K (takes a long time, multiple doses), but why wouldnt you wanna give FFP if her INR is still off?
Click to expand...


Tourniquet....and bad heart failure.....but would give it if there is excessive bleeding after tq is off.
 
The FFP and vit K are used to help ward off that "evil ooze" that can happen post op when pt. is back in her room and the 10 family members are hovering around the bed looking at that bandaged stump and now blood is oozing onto the bedsheets. The 10 simpletons freak, running out to the nurses desk filled with hysteria and demanding to have surgeon come see pt. Surgeon ain't got no time for all this BS. I'm trying to prevent all that. It's all big picture as I've been around the block a time or two.---- Zippy
 
jetproppilot said:
These are very good questions, Vent. I'll give you my expert :laugh: opinion.

Subclinical coagulopathies got alotta press in the anesthesia literature a year or so after the low molecular weight heparins came out. What I mean by subclinical is you get the coags and they're normal, but enough medicine was still present to cause some epidural hematomas, so a warning letter was issued.
I"ll do regional if the last LMWH dose was 12 hours or greater ago.

Clopidogrel (Plavix) acts by irreversibly affecting the platelet ADP receptor, with a half life of 7 days, but normal platelet aggregation returns in about 5 days, so I use 5 days as my cutoff for this drug, since there have been reports of hematomas if you do regional before that.

SQ heparin is kinda tricky since the absorption is so variable. I use 12 hours for the cutoff here.

IV heparins half life is short, hence the infusion required. Half life around 90 minutes. 6-8 hours off IV heparin and you're probably golden, but I'll check a PTT before.

5 days off coumadin and you're probably alright. Best to check a PT before anyway. Sometimes I order one, sometimes I dont.

Aspirin doesnt bother me.

I'm comfortable putting in a spinal or epidural for a case that requires heparinization intraop, like a fem pop. Prefer a spinal since you dont have to worry about waiting a while to pull the epidural after the case is over.

Just my personal comfort levels.
Click to expand...

Word. 👍
 
Aspirin said:
You might want to wait a little while (5-7days for Plavix, 7-10days for clopridigel) for these before sticking them in the back. Not for ASA however. Plavix is more dangerous than our surgical colleges think.
Click to expand...
 
Noyac said:
You might want to wait a little while (5-7days for Plavix, 7-10days for clopridigel) for these before sticking them in the back. Not for ASA however. Plavix is more dangerous than our surgical colleges think.
Click to expand...

Plavix and cloridogrel is the same medicine. Plavix=trade name clopidogrel=generic name.
 
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
 
drrinoo said:
This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature
Click to expand...

You would be Professor of what & where?
 
drrinoo said:
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
Click to expand...

Instead of posting a dead link, why not just enlighten us a little? What misinformation? Be specific. And besides - this is a DISCUSSION forum, not a journal review. Why not participate in the DISCUSSION instead of posting a self-serving journal citation? The subject has hardly been "exhaustively beaten to death" - pretty much anything is open to reasonable discussion and honest differences of opinion. And 900 hours? Wow, that's about four months of my work schedule, just for me. And you have six co-authors.

And us "private practice slicks" operate in the REAL WORLD, not academia. Trust me - the rules are much different.
 
drrinoo said:
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
Click to expand...

Oh, sorry, Slim. Didnt realize it was bad to share info with residents based on experience. And the only reason I'm not beating into you for your "private practice slicks" derogatory, stupid ass comment is Alan Kaye is a buddy of mine.
Go back to playing Frogger on your Atari.
 
drrinoo said:
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
Click to expand...

Oh, and thanks alot for the dead end link. Arrogant @@shole.
 
jwk said:
Instead of posting a dead link, why not just enlighten us a little? What misinformation? Be specific. And besides - this is a DISCUSSION forum, not a journal review. Why not participate in the DISCUSSION instead of posting a self-serving journal citation? The subject has hardly been "exhaustively beaten to death" - pretty much anything is open to reasonable discussion and honest differences of opinion. And 900 hours? Wow, that's about four months of my work schedule, just for me. And you have six co-authors.

And us "private practice slicks" operate in the REAL WORLD, not academia. Trust me - the rules are much different.
Click to expand...

👍 👍
 
drrinoo said:
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
Click to expand...

Oh, and one more thing, "Doctor", my post ended with "just my personal comfort levels." I've been in busy, regional oriented practices since 1996, and havent had a bleeding complication yet.
OH, SORRY, I FORGOT. IT DOESNT COUNT. I DIDNT PUBLISH IT. I WAS TOO BUSY DOING CASES.
 
drrinoo said:
Way too much misinformation in these posts.

This subject has been exhaustively beaten to death and is readily accessible in the peer reviewed literature.

This is one of the unfortunate dangers of medical blogs....and you private practice slicks should know better than to encourage the residents to listen to your posts than to search the medical literature

here is my article...freely accessible...it has all the pertinent references until the end of 2003...(900+ hours of work)

www.painphysicianjournal.org, Jan 2004

P 3
Bleeding Risk in Interventional Pain Practice: Assessment, Management, and Review of the Literature
Current Opinion

P. Prithvi Raj, MD, Rinoo V. Shah, MD, Alan D. Kaye, MD Ph D, Stephen Denaro, BS, and Jason M. Hoover, BS

Abstract. Full Text
Click to expand...

And since I'm on a roll ( :laugh:), I'm an MD too, and the Chief of an anesthesia department. Insecurity, however, has not lead me to put my name, degree, and title above my avatar.
 
Hey, Jet. Speaking of Avatars...I just rode the Dragon at Deal's Gap in North Carolina on my Interceptor...Scared the living $hit out of myself... Should have a photo in the near future for an Avatar.
 
Ooh, an attending squabble. Love those. 🙂

The link should be painphysicianjournal.com, not .org. Dr. Shah is (was?) an assistant prof at Texas Tech. Hope that helps.
 
asdash said:
Ooh, an attending squabble. Love those. 🙂

The link should be painphysicianjournal.com, not .org. Dr. Shah is (was?) an assistant prof at Texas Tech. Hope that helps.
Click to expand...

900 hours of work and can't get a simple URL correct for your own research? Hmmmmmmmmmm.................. +pity+
 
OK, I actually read some of the article - much of it total fluff, although since it's a "review article", I guess that's OK. But they offer up a concept of "overall bleeding risk score", which although interesting, includes this little itty-bitty but important line that says "ALTHOUGH NOT VALIDATED..."

That hardly makes the conclusions in this single article in a relatively minor journal something that should be the basis of widespread clinical practice.

Better yet, why not follow the recommenations of the ASRA, a much more widely recognized group, whose consensus statement on neuraxial anesthesia and anticoagulation is summarized as follows:

"Regional Anesthesia in the Anticoagulated Patient
Summary
Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective-randomized study, and there is no current laboratory model. As a result, these consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. They are based on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management; a "cookbook" approach is not appropriate. Rather, the decision to perform spinal or epidural anesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, though definite risk of spinal hematoma with the benefits of regional anesthesia for a specific patient. Alternative anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The patient's coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation must be carefully monitored during the period of epidural catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal hematoma. It must also be remembered that identification of risk factors and establishment of guidelines will not completely eliminate the complication of spinal hematoma. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention. We must focus not only on the prevention of spinal hematoma, but also optimization of neurologic outcome."


So in the meantime, we'll continue to do our 20,000 epidurals a year, checking the appropriate labs as clinically indicated, and playing it safe when those labs or the patients history and physical exam indicate that regional might not be the best way to go on that particular day.
 
militarymd said:
Hey, Jet. Speaking of Avatars...I just rode the Dragon at Deal's Gap in North Carolina on my Interceptor...Scared the living $hit out of myself... Should have a photo in the near future for an Avatar.
Click to expand...

WOW DUDE! You have bigger cajones than me! Can't wait to see some pics...
 
jwk said:
OK, I actually read some of the article - much of it total fluff, although since it's a "review article", I guess that's OK. But they offer up a concept of "overall bleeding risk score", which although interesting, includes this little itty-bitty but important line that says "ALTHOUGH NOT VALIDATED..."

That hardly makes the conclusions in this single article in a relatively minor journal something that should be the basis of widespread clinical practice.

Better yet, why not follow the recommenations of the ASRA, a much more widely recognized group, whose consensus statement on neuraxial anesthesia and anticoagulation is summarized as follows:

"Regional Anesthesia in the Anticoagulated Patient
Summary
Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective-randomized study, and there is no current laboratory model. As a result, these consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. They are based on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management; a "cookbook" approach is not appropriate. Rather, the decision to perform spinal or epidural anesthesia/analgesia and the timing of catheter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weighing the small, though definite risk of spinal hematoma with the benefits of regional anesthesia for a specific patient. Alternative anesthetic and analgesic techniques exist for patients considered an unacceptable risk. The patient's coagulation status should be optimized at the time of spinal or epidural needle/catheter placement, and the level of anticoagulation must be carefully monitored during the period of epidural catheterization. Indwelling catheters should not be removed in the presence of therapeutic anticoagulation, as this appears to significantly increase the risk of spinal hematoma. It must also be remembered that identification of risk factors and establishment of guidelines will not completely eliminate the complication of spinal hematoma. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt intervention. We must focus not only on the prevention of spinal hematoma, but also optimization of neurologic outcome."


So in the meantime, we'll continue to do our 20,000 epidurals a year, checking the appropriate labs as clinically indicated, and playing it safe when those labs or the patients history and physical exam indicate that regional might not be the best way to go on that particular day.
Click to expand...

thanx a mil for your work and the post, jwk.
 
jetproppilot said:
thanx a mil for your work and the post, jwk.
Click to expand...

jwk and jetprop

the reason we developed a bleeding risk score is so that a nurse or even a receptionist could theoretically administer the questionnaire and notify the pain specialist/regional anesthesiologist that a patient could be in a higher or lower bleeding risk stratification. this may save some time and enhance patient safety.

additionally, the ASRA guidelines have really been developed to address spinals and epidurals....but not for the large variety of pain procedures and regional anesthetics .

we also could not say that this instrument has been validated nor could we say these are standards promulgated by one society, because we don't know.

In fact, that is why ASRA came up with guidelines, instead of standards, because any deviation from a standard has inherent medicolegal risk. The ASA closed claims data in 1999 suggests thatan increasing proportion of claims were paid out for regional anesthetic/pain procedure complications, as compared to the 1990 closed claims study, in which a number of claims for neural injuries were attributed to positioning.

juries often don't have patience for complicated medical explanations...and it is easy for them to see pre-op normal neurological exam patient (on coumadin stopped 7 days ago)....post-op epidural hematoma...as simple as cause and effect and bad judgment...even though a PT/INR may not be needed


jetprop....the risk of bleeding with spinals is 1:220,000 and with epidurals 1:150,000....the odds are in your favor of not developing a complication if you have done 20,000.....

the original post suggested that the patient came off coumadin just 2 days earlier...you could check a PT/INR....the recommendations are typically that neuraxial procedures are safe to do if the INR is less than 1.5....

ironically, an INR 1.5 may present different bleeding risks.....

starting someone on coumadin and increasing their INR from 1 to 1.5 has less of a bleeding risk than taking someone off of coumadin and allowing their INR to fall from 2.5 to 1.5

no comments on not being invited to the jetprop and jwk circle jer--
 
drrinoo said:
jwk and jetprop

the reason we developed a bleeding risk score is so that a nurse or even a receptionist could theoretically administer the questionnaire and notify the pain specialist/regional anesthesiologist that a patient could be in a higher or lower bleeding risk stratification. this may save some time and enhance patient safety.
Click to expand...
Thanks - I think we'll stick to doing our own interpretation, rather than have the receptionist do it.

drrinoo said:
additionally, the ASRA guidelines have really been developed to address spinals and epidurals....but not for the large variety of pain procedures and regional anesthetics .
Click to expand...

The original post was about a spinal anesthetic. No mention of pain procedures that I see.

drrinoo said:
we also could not say that this instrument has been validated nor could we say these are standards promulgated by one society, because we don't know.
Click to expand...
Yet you post this link hoping everyone will use it, even though admittedly the concept itself hasn't had any peer review to see if it's valid.

drrinoo said:
the original post suggested that the patient came off coumadin just 2 days earlier...you could check a PT/INR....the recommendations are typically that neuraxial procedures are safe to do if the INR is less than 1.5....

ironically, an INR 1.5 may present different bleeding risks.....

starting someone on coumadin and increasing their INR from 1 to 1.5 has less of a bleeding risk than taking someone off of coumadin and allowing their INR to fall from 2.5 to 1.5
Click to expand...
Back to the original question. Would you put a spinal in a fragile old lady off of her coumadin for a couple of days without repeating her coags first? I don't need a bleeding risk score to say no.
 
drrinoo said:
the reason we developed a bleeding risk score is so that a nurse or even a receptionist could theoretically administer the questionnaire and notify the pain specialist/regional anesthesiologist that a patient could be in a higher or lower bleeding risk stratification. this may save some time and enhance patient safety.
Click to expand...

Dr. Roo,

The way your initial post read, it implied that we (private slicks) don't know much, and you (assist prof) knows what IS. Sounds like you just made some stuff up (meaning non-validated), published in some journal that only a minority of physicians read, and call it the RIGHT thing to do????

By the way, I have an assist prof appointment too that I gave up last year.

drrinoo said:
additionally, the ASRA guidelines have really been developed to address spinals and epidurals.....
Click to expand...

Not Guidelines...just Consensus Statement...as an academic, you should know the difference.

drrinoo said:
the original post suggested that the patient came off coumadin just 2 days earlier...you could check a PT/INR....the recommendations are typically that neuraxial procedures are safe to do if the INR is less than 1.5....
Click to expand...

Correct me if I'm wrong, but I believe an INR of 1.5 is only ok in the setting of starting coumadin after surgery when it is on its way up....because the test looks at factor VII levels which goes down first....and it is usually for removing an epidural catheter placed for post op pain

INR of 1.5 on its way down is NOT ok in my book....but then there is so little data.

The whole point of this discussion.
 
militarymd said:
Hey, Jet..I just rode the Dragon at Deal's Gap in North Carolina on my Interceptor...Scared the living $hit out of myself..
Click to expand...

Mil,
I'm scared of ledges...kinda funny...being in a cockpit doesnt bother me....
cant imagine going around a curve on a crotch rocket and looking down.. 😱
 
jetproppilot said:
Mil,
I'm scared of ledges...kinda funny...being in a cockpit doesnt bother me....
cant imagine going around a curve on a crotch rocket and looking down.. 😱
Click to expand...

Like I said, I was scared. I went with a plastic surgeon. He was riding a GTS, a BIG bike. I kept up with him at first, but then fear took over, and Ilet him go on without me. He was scraping his foot pegs on every turn (sparks)....meaning no room for error.
 
jetproppilot said:
Mil,
I'm scared of ledges...kinda funny...being in a cockpit doesnt bother me....
cant imagine going around a curve on a crotch rocket and looking down.. 😱
Click to expand...

That's because you know your vehicle is designed to take you UP if you fly off a cliff. Military's rocket has only one way to go in that situation: with gravity. 😀
 
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