BTKA on heparin/ PDPH with epidural in

[VentdependenT]

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2 questions on practice manages:

1)Large fella threw PE, in the unit, has 10/10 pain s/p BTKA. He's on a heparin ggt.

-would you add toradol to someone on systemic anticoagulation. I didnt.
-would you attempt u/s guided femoral nerve block with 22g b-bevel? I wouldn't.

I just threw his butt on dilauded PCA and had the nurse leave some narcan by the bedside.

2) 50 y/o female with possible PDPH and a working epidural. Currently on IV caffeine and wait n' see protocol.
-Would you draw blood sterile and give it through the epidural (which is less than 24hours old)?
-Would you yank it and give the blood through a touhy?

 

[Planktonmd]

2 questions on practice manages:

1)Large fella threw PE, in the unit, has 10/10 pain s/p BTKA. He's on a heparin ggt.

-would you add toradol to someone on systemic anticoagulation. I didnt.
-would you attempt u/s guided femoral nerve block with 22g b-bevel? I wouldn't.

I just threw his butt on dilauded PCA and had the nurse leave some narcan by the bedside.

2) 50 y/o female with possible PDPH and a working epidural. Currently on IV caffeine and wait n' see protocol.
-Would you draw blood sterile and give it through the epidural (which is less than 24hours old)?
-Would you yank it and give the blood through a touhy?

1- Agree, IV PCA no NSAID's, you can also add some Ketamine, If you really have to do the nerve block stop the heparin 2 hours.
2- I don't do blood patches through epidural catheters because it's really hard to push blood through such a thin catheter and because of infection risk, so take it out and do the blood patch, you could try some Cosyntropin IV as well.

 

[Mman]

What's the problem with an ultrasound guided femoral nerve block? The chances of getting an arterial puncture are probably under 1%. I mean you can see the needle and you can see the artery, so long as you don't go blindly jabbing the needle it should not happen.

And even if it does? It's a compressible site and the guy already has a BKA on that leg. I figure if all those groin hematomas after cardiac caths and balloon pumps and everything else usually turn out OK, a 22 guage needle stick can't do that much even if it hits the artery. Hold pressure for 30 minutes and it should be OK.

 

[coprolalia]

-would you add toradol to someone on systemic anticoagulation. I didnt.

I agree. No toradol. But, you can give neurontin and tylenol. You'll probably get better coverage for potential "phantom" pain with neurontin. Also, extremely low dose ketamine (as was mentioned) might work, but most places are hesitant to do this.

-would you attempt u/s guided femoral nerve block with 22g b-bevel?

No reason not to try it, except that you are going to miss the sciatic distribution. A three-in-one block will cover most of the upper leg. For a true BKA, you'll get better cover lower extremity coverage with a sciatic block. What about a lumbar plexus and sciatic?

I just threw his butt on dilauded PCA and had the nurse leave some narcan by the bedside.

That works too. 🙂

2) 50 y/o female with possible PDPH and a working epidural. Currently on IV caffeine and wait n' see protocol.
-Would you draw blood sterile and give it through the epidural (which is less than 24hours old)?
-Would you yank it and give the blood through a touhy?

I'd keep going with the conservative approach for now. You can pull the epidural and place a Tuohy for blood patch when you pull the catheter, if she still has the headache. If it is TRULY a positional headache, just leave her in bed for now. (P.S. Coffee/tea works well too and is a heck of a lot cheaper than IV caffeine. You can always buy her some Starbucks. )

-copro

 

[VentdependenT]

What's the problem with an ultrasound guided femoral nerve block? The chances of getting an arterial puncture are probably under 1%. I mean you can see the needle and you can see the artery, so long as you don't go blindly jabbing the needle it should not happen.

And even if it does? It's a compressible site and the guy already has a BKA on that leg. I figure if all those groin hematomas after cardiac caths and balloon pumps and everything else usually turn out OK, a 22 guage needle stick can't do that much even if it hits the artery. Hold pressure for 30 minutes and it should be OK.

He's going to be on continuous systemic anticoagulation for his PE. Not some plavix and aspirin like a post-stent guy but a heparin drip.

I've never had to hold pressure on someone with a heparin drip before but I'm sure things will clot eventually.

I agree that the incidence is low but man, it just makes me a bit nervous.

 

[sdn1977]

2 questions on practice manages:

1)Large fella threw PE, in the unit, has 10/10 pain s/p BTKA. He's on a heparin ggt.

-would you add toradol to someone on systemic anticoagulation. I didnt.
-would you attempt u/s guided femoral nerve block with 22g b-bevel? I wouldn't.

I just threw his butt on dilauded PCA and had the nurse leave some narcan by the bedside.

2) 50 y/o female with possible PDPH and a working epidural. Currently on IV caffeine and wait n' see protocol.
-Would you draw blood sterile and give it through the epidural (which is less than 24hours old)?
-Would you yank it and give the blood through a touhy?

I wouldn't add tordol (would make my computer go red flags all over & I'd have to call you - not good). Its not that you can't do it - it just changes your labs & doesn't really add that much for analegesia, IMO>

I like the dilaudid PCA - the gabapentin will take time to work - don't expect results right now, but in the long run - its pretty good for this.

Can't give you any infor on #2, but nurses HATE caffeine IV - don't know why. Its always nice when you guys give it prophylactically after a case in someone who drinks coffee routinely & will be npo for a day or so.

 

[Gator05]

Why the BKA? Or is this bilat TKA?

What exactly will the femoral block cover? If it's truly and well BELOW the knee, not sure what the goal is of a femoral NB.

Dilaudid is great, I'd bolus ketamine as well if refractory, lyrica as well.

I ask about the BKA reason because if the extremity has been long-devascularized, it may not hurt much and PCA may be adequate. Plus, your surgeons could have surgically placed a sciatic nerve catheter. Not only will this help with your pain control, but will minimize phantom limb pain later on.

Finally, risks and benefits; if you can't get on top of the bone-pain with narcotics, and they guy's a vasculopath, the risks of continued inadequately opposed sympathetic outflow (and prolonged bed rest) may justify the benefits of superb pain control via regional.

 

[hokie]

No reason not to try it, except that you are going to miss the sciatic distribution. A three-in-one block will cover most of the upper leg. For a true BKA, you'll get better cover lower extremity coverage with a sciatic block. What about a lumbar plexus and sciatic?



I would avoid a lumbar plexus while anticoagulated

 

[VentdependenT]

Why the BKA? Or is this bilat TKA?

What exactly will the femoral block cover? If it's truly and well BELOW the knee, not sure what the goal is of a femoral NB.

Dilaudid is great, I'd bolus ketamine as well if refractory, lyrica as well.

I ask about the BKA reason because if the extremity has been long-devascularized, it may not hurt much and PCA may be adequate. Plus, your surgeons could have surgically placed a sciatic nerve catheter. Not only will this help with your pain control, but will minimize phantom limb pain later on.

Finally, risks and benefits; if you can't get on top of the bone-pain with narcotics, and they guy's a vasculopath, the risks of continued inadequately opposed sympathetic outflow (and prolonged bed rest) may justify the benefits of superb pain control via regional.

Bilateral total knee replacement

 

[VentdependenT]

No reason not to try it, except that you are going to miss the sciatic distribution. A three-in-one block will cover most of the upper leg. For a true BKA, you'll get better cover lower extremity coverage with a sciatic block. What about a lumbar plexus and sciatic?



I would avoid a lumbar plexus while anticoagulated

What? You don't like seeing turners sign on your patients from a massive retroperitoneal bleed?

 

[Planktonmd]

What? You don't like seeing turners sign on your patients from a massive retroperitoneal bleed?

🙂
I have seen massive retroperitoneal bleeding after Femoral artery injury too.
I really think it's too aggressive trying to do any regional block on a patient who is recieving therapeutic doses of heparin.

 

[Noyac]

Can't give you any infor on #2, but nurses HATE caffeine IV - don't know why.

Because it doesn't work.

 

[epidural man]

2) 50 y/o female with possible PDPH and a working epidural. Currently on IV caffeine and wait n' see protocol.
-Would you draw blood sterile and give it through the epidural (which is less than 24hours old)?
-Would you yank it and give the blood through a touhy?

At busy OB hospital in town here they do blood through the catheter routinely (as routinely as needed - I don't think a PDPH is very routine there, but you get my point).

In fact, I think they may do it prophylactically if they got a wet tap.

I would do it. I have pushed blood through a freshly placed catheter before. (I got the space, the other resident couldn't draw blood for a long time, so I threaded the catheter so the patient could lay down and relax while they poked her arm/hand - rather than sit there with a huge needle sticking in her back) - and it was hard to push but it had immediate results just like most blood patches have done for me.

 

[sdn1977]

Because it doesn't work.

Thats always been my thought......it does crank up the hr sometimes though.

 

[tussionex]

Thats always been my thought......it does crank up the hr sometimes though.

i second that. we always scramble to find it/borrow it....only to have nursing grumble. [and probably the patient as well]
i once saw fioricet ordered for PDPH. huh? not THAT much caffeine in there...and really ineffective for any headache. tried to talk them out of it. any thoughts, sdn?

 

[lobelsteve]

I'd keep going with the conservative approach for now. You can pull the epidural and place a Tuohy for blood patch when you pull the catheter, if she still has the headache. If it is TRULY a positional headache, just leave her in bed for now. (P.S. Coffee/tea works well too and is a heck of a lot cheaper than IV caffeine. You can always buy her some Starbucks. )

-copro

I think starbucks is more expensive than VI caffeine.

No deep needles on a heparin drip. PCA makes a lot of sense.
TKA not BKA- no phantom limb, just aching knees. Can the surgeon run a local drip into the joint through the little ball irrigator?

PDPH: Evidence for treatment is minimal with caffeine or other meds. Hydration and a blood patch. Getting the epdiural catheter out would help make it go away faster (pressure differential).

 

[beezar]

I would do a u/s guided femoral block in a heart beat. But then again, if you've only done one of them, this isn't the patient to do your 2nd.

Most of your pain (front, sides, most of the knee joint) is covered by the femoral block. The sciatic block covers the back of the knee. After doing lots of TKA's with femoral/sciatic blocks, and femoral blocks alone, and no blocks, the best pain relief is with femoral/sciatic, obviously, but you get a ton of pain relief with femoral blocks alone compared with no blocks (many studies show this as well)

Regarding the heparin issue, with U/S guidance, it is really really hard to hit the artery. And if you're still concerned, you can still do a fascia iliaca block (far away from the artery) under U/S guidance and get spread to the femoral nerve.

my 2 cents.

 

[VentdependenT]

Thought about the Fascia Iliaca block. By the time I did the Dilauded had done her job.

I could blind stick for the fascia iliaca block like we usually do based on landmarks. Never thought I'd be able to make out the two fascial layers with an ultrasound. Will think about trying it next time.

 

[Tenesma]

i have had a patient die after femoral procedure was done while they were anti-coagulated - don't recommend it

don't do regional while anti-coagulated - it is NOT standard of care and you will be hung out to dry

PDPH... conservative care - and if necessary do a blood patch through tuohy, not catheter - you want this to be as sterile a procedure as possible and those catheters are yucky after a bit...

it appears less and less people are doing blood patches in the community - in fact a lot of ERs and Neurologists are just telling patients to lay down for 7 - 10 days...

 

[VentdependenT]

i have had a patient die after femoral procedure was done while they were anti-coagulated - don't recommend it

don't do regional while anti-coagulated - it is NOT standard of care and you will be hung out to dry

PDPH... conservative care - and if necessary do a blood patch through tuohy, not catheter - you want this to be as sterile a procedure as possible and those catheters are yucky after a bit...

it appears less and less people are doing blood patches in the community - in fact a lot of ERs and Neurologists are just telling patients to lay down for 7 - 10 days...

just long enough to get a post op PE.

 

[Tenesma]

yeah - but if it's a PE they can turf it to internal medicine or pulmonary...