Epidural and Lovenox/Heparin??

[HeyDoc]

I'm a TY and going to start CA-1 in Anesthesiology soon. I have seen this subject come up on a monthly basis between Anes. and Surgery. Typical it's a Trauma case with a patient with a flail chest and in extreme pain. Surgery wants to have an epidural placed but Anesthesia refuses due to patient is on Lovenox. Surgery refuses to DC Lovenox due to the guy is bedrest and risk of DVT/PE. Now my question is what do my fellow Anesthesiologist do in this situation?? Is there any literature supporting stopping Lovenox, insert epidural and then restarting Lovenox with catheter in place (risk of epidural hematoma still there???). Here at my current institution if the Lovenox is not stopped they don't put the epidural catheter in and catheter has to be removed before Lovenox is restarted.

Thanks and appreciate any reference to supporting literature one way or another. I'm beginning to start putting myself in the Anesthesiologist shoes 🙂 and trying to figure out what I would do and what supports my decision.

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[Platysma]

Google the American Society of Regional Anesthesia, go to their webpage. There are consensus guidelines on that page as far as anticoagulation goes and neuraxial block.

For Lovenox, the guidelines state that for prophylaxis doses, Lovenox should be held for at least 12 hours prior to needle placement. For full anticoagulation doses, Lovenox should be held for 24 hours. As far as surgery pushing for an epidural, well, if they want to cause a spinal hematoma and paralyze the patient, then they can place the freaking epidural themselves. Most surgeons are not so stupid to push for neuraxial blocks in that case. If the pain control is really that important, then they need to stop the lovenox and use SCDs or some alternate method of dvt prophylaxis.

As far as catheter placement, it depends on whether you are doing bid or qd dosing. For bid dosing, it is recommended to remove any indwelling catheters. For qd dosing, you can have the catheter in, so long as lovenox is started 6-8 hours post placement, and that the cather is removed 10-12 hours post discontinuation of lovenox.

http://www.asra.com/Consensus_Conferences/neuraxial_anesthesia.shtml

Platysma
CA-1 New York-Presbyterian Hospital

I'm a TY and going to start CA-1 in Anesthesiology soon. I have seen this subject come up on a monthly basis between Anes. and Surgery. Typical it's a Trauma case with a patient with a flail chest and in extreme pain. Surgery wants to have an epidural placed but Anesthesia refuses due to patient is on Lovenox. Surgery refuses to DC Lovenox due to the guy is bedrest and risk of DVT/PE. Now my question is what do my fellow Anesthesiologist do in this situation?? Is there any literature supporting stopping Lovenox, insert epidural and then restarting Lovenox with catheter in place (risk of epidural hematoma still there???). Here at my current institution if the Lovenox is not stopped they don't put the epidural catheter in and catheter has to be removed before Lovenox is restarted.

Thanks and appreciate any reference to supporting literature one way or another. I'm beginning to start putting myself in the Anesthesiologist shoes 🙂 and trying to figure out what I would do and what supports my decision.

 

[HeyDoc]

As far as catheter placement, it depends on whether you are doing bid or qd dosing. For bid dosing, it is recommended to remove any indwelling catheters. For qd dosing, you can have the catheter in, so long as lovenox is started 6-8 hours post placement, and that the cather is removed 10-12 hours post discontinuation of lovenox.


Good stuff Platysma, but where do you come up with this info. on catheters? This is the debated issue where a catheter can be in place while pt is on Lovenox. Thanks for the link.

 

[Platysma]

As far as catheter placement, it depends on whether you are doing bid or qd dosing. For bid dosing, it is recommended to remove any indwelling catheters. For qd dosing, you can have the catheter in, so long as lovenox is started 6-8 hours post placement, and that the cather is removed 10-12 hours post discontinuation of lovenox.


Good stuff Platysma, but where do you come up with this info. on catheters? This is the debated issue where a catheter can be in place while pt is on Lovenox. Thanks for the link.

i got the information from the website. It has a lot of stuff concerning epidural catheters not just for lovenox, but for other anticoagulation agents

Platysma
CA-1 NYPH-Columbia