Epidural and INR feedback

[interjectionreflection]

Hi guys. Just wanted to get some honest feedback. I have very few patients on warfarin in my practice. There was a patient I have on warfarin waiting for epidural. He was given advice by his hematologist to hold warfarin 5 days. But I told him I want the INR to be <1.5 so he can check it 24-48 before procedure. From what I can tell this is in line with ASRA guidelines. I got a very snarky note from his hematologist saying the plan is "not reasonable" and patient just needs to hold warfarin 5 doses. No INR check would be required. This hematologist is particularly very vocal and rude to a lot of my colleagues. I wanted to know what you do with warfarin and if those doing anesthesia do something different when it comes to OR?

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[buddababa]

Hi guys. Just wanted to get some honest feedback. I have very few patients on warfarin in my practice. There was a patient I have on warfarin waiting for epidural. He was given advice by his hematologist to hold warfarin 5 days. But I told him I want the INR to be <1.5 so he can check it 24-48 before procedure. From what I can tell this is in line with ASRA guidelines. I got a very snarky note from his hematologist saying the plan is "not reasonable" and patient just needs to hold warfarin 5 doses. No INR check would be required. This hematologist is particularly very vocal and rude to a lot of my colleagues. I wanted to know what you do with warfarin and if those doing anesthesia do something different when it comes to OR?

you're correct, what if the patient is supra-therapeutic and holds it for 5 days? Tell this hematologist i will follow your guidelines if you will gladly take my place in a lawsuit

 

[willabeast]

Hi guys. Just wanted to get some honest feedback. I have very few patients on warfarin in my practice. There was a patient I have on warfarin waiting for epidural. He was given advice by his hematologist to hold warfarin 5 days. But I told him I want the INR to be <1.5 so he can check it 24-48 before procedure. From what I can tell this is in line with ASRA guidelines. I got a very snarky note from his hematologist saying the plan is "not reasonable" and patient just needs to hold warfarin 5 doses. No INR check would be required. This hematologist is particularly very vocal and rude to a lot of my colleagues. I wanted to know what you do with warfarin and if those doing anesthesia do something different when it comes to OR?

Tell him you are simply CYA. Hematomas happen, patients don't follow directions, and defensive medicine is smart medicine.

 

[lobelsteve]

Ignore the troll heme/onc.
INR 1.4 or less.
Or why is the patient on warfarin?
What is risk of holding vs not holding?
What technique will be used?
I'd do it all day with INR 2.5 or less.

 

[OM1027]

transforaminal, do not hold warfarin

 

[Quixotic2501]

In my experience, hematologists have very little idea of the risks involved with neuraxial procedures, e.g. giving stronger recommendations about holding anticoagulation, giving DDAVP or factor replacement, etc. for things like a colonoscopy or a minor surgical procedure versus a cervical epidural. Take their advice with a grain of salt, and engage in conversation if their recommendations seem crazy.

I know a lot of people are a little bit more cavalier with holding anti-coagulation depending on the approach and area being worked on and will point to other studies or case series or personal experience. I'm not gonna argue with that, but I do want to point out that you're misunderstanding the ASRA guidelines. You're mostly right. ASRA recommends holding warfarin for 5 days, testing INR, and having the INR return to normal before proceeding. This is <=1.2, and that number is stated so in the guidelines. I often see others make the same mistake. For a patient not on coumadin, the recommendation is typically an INR of 1.4 or less, but don't get those different scenarios confused. My patients will either get a POC INR or lab drawn INR hours before their procedure, but I understand I may be a little more privileged in that sense.

 

[nvrsumr]

That’s interesting. Misinterpreted for years then. Haven’t had a patient on warfarin in 5 years rhough

 

[stsa84]

Yeah, I do 5 days + INR of 1.2 or less. If INR is high, hold another day and check INR again. Don't see much reason to go against guidelines.

 

[lobelsteve]

Yeah, I do 5 days + INR of 1.2 or less. If INR is high, hold another day and check INR again. Don't see much reason to go against guidelines.

Because those guidelines kill people

 

[SSdoc33]

1.4

 

[Dr. Ice]

Aren’t there supposed to be new ipsis recommendations for holding thinners for neuroaxial procedures or are we all just postulating still?

 

[Baron Samedi]

Do you guys use the same INR cutoff for liver patients?

 

[SSdoc33]

Aren’t there supposed to be new ipsis recommendations for holding thinners for neuroaxial procedures or are we all just postulating still?

they've been avoiding responsibility for a decade. id love to see it not holding my breath

 

[interjectionreflection]

transforaminal, do not hold warfarin

Its for a interlaminar

In my experience, hematologists have very little idea of the risks involved with neuraxial procedures, e.g. giving stronger recommendations about holding anticoagulation, giving DDAVP or factor replacement, etc. for things like a colonoscopy or a minor surgical procedure versus a cervical epidural. Take their advice with a grain of salt, and engage in conversation if their recommendations seem crazy.

I know a lot of people are a little bit more cavalier with holding anti-coagulation depending on the approach and area being worked on and will point to other studies or case series or personal experience. I'm not gonna argue with that, but I do want to point out that you're misunderstanding the ASRA guidelines. You're mostly right. ASRA recommends holding warfarin for 5 days, testing INR, and having the INR return to normal before proceeding. This is <=1.2, and that number is stated so in the guidelines. I often see others make the same mistake. For a patient not on coumadin, the recommendation is typically an INR of 1.4 or less, but don't get those different scenarios confused. My patients will either get a POC INR or lab drawn INR hours before their procedure, but I understand I may be a little more privileged in that sense.

thanks for pointing that out, I guess we have to be more conservative

Im confused because I have always checked it. But I talked to a few people who gave me varying responses. Some say they never check INR after holding for 5 days. This hematologist is nationally renowned for this and his response essentially said I was being very unreasonable and my suggestion was amateur. Just wanted to make sure I am not being overly conservative.

 

[drmamba]

Yeah we need a pain society to come up with updated guidelines. ASRA guidelines were developed by non-chronic pain academics with no skin in the game for longitudinal patient care, and different practice setting with different patient population. The fact that many ivory towers still push for holding AC meds for TFESIs and baby aspirin/NSAIDs for ILESIs based on archaic guidelines is absurd.

 

[Ducttape]

No you are not. I have had patients who have held warfarin for 5 days come back with INR > 2. One person had to hold it for 2 weeks.

Medication noncompliance had a big role. He routinely would not take Coumadin for weeks at a time and when he would come in to hospital he would be found to have normal levels even on therapeutic doses, so they kept increasing instead of addressing issue of noncompliance.

 

[lobelsteve]

ILESI with 25g spinal needle. No hold.

 

[callmeanesthesia]

https://jamanetwork.com/journals/jama/article-abstract/2830847

Just saw this posted. Seems very relevant to this discussion. Maybe it will help swing us toward more balanced blood thinner protocols.

 

[clubdeac]

I think that was the old school way of doing it. I vaguely remember attendings doing that where I trained. Never checked an INR. Seems dumb now

 

[bedrock]

ILESI with 25g spinal needle. No hold.

Hm. I might consider this for a lumbar ILESI.

 

[lobelsteve]

I do every day.

 

[Orin]

ASRA guidelines comes from a world where epidurals are icing on the cake and not the cake itself, when folks were freaked out about the kinetics of LMWH and increases in epidural hematomas. They're far too conservative and I agree with Lobel they're likely causing harm as patients get sicker/more complex.

 

[Orin]

https://jamanetwork.com/journals/jama/article-abstract/2830847

Just saw this posted. Seems very relevant to this discussion. Maybe it will help swing us toward more balanced blood thinner protocols.

This is the shift in legal mindset from 'standard of care' towards the 'reptilian mind' argument that is forcing more lawsuits.

The Reptile Brain Strategy: Why Lawyers Use It and How to Counter It | JD Supra

Over the years, we have heard much consternation from our clients regarding a plaintiff strategy called the “Reptile Approach.” We have seen this...

www.jdsupra.com

Reptile Theory: A History and 5 Ways to Win Before Trial - Idelic

For fleets looking to shore up their liability in the wake of these trends, understanding reptile theory is crucial to their success.

idelic.com

 

[Baron Samedi]

Nothing worse than having a pt hold their blood thinner for several days just to have their procedure cancelled due to elevated blood sugar or hypertension.