epidural and lovenox

[prongs]

I have a patient with thoracic epidural for ivor lewis esophagectomy. Surgeon wants to use prophylactic BID lovenox, as high risk cancer patient. I told him no, but SQ heparin is ok. He states that he has been doing it at another hospital where he works (with different anesthesia group) for the last 5 years. Who is doing this?

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[ryanjmy]

I believe the guidlines say you can start prophylaxis dose 6 hrs after placement. Treatment dose is contraindicated.

 

[G0S2]

We do Lovenox 40 at 1700. That way cath could be pulled next am. BID makes it difficult time wise.

 

[psychbender]

No BID lovenox with neuraxial catheters at any hospital where I have worked. If he really wants more anticoagulation, then no epidural.

 

[pgg]

We don't do bid LMWH dosing with a neuraxial catheter in place, and I've never worked any place where that's accepted practice.


I like this cheat sheet -

guidelines (pdf)


Also, ASRA applies the same guidelines to peripheral blocks/catheters, which I think is silly, but I follow the guidelines anyway.

 

[TrustMe]

I ran unto the same issue with one of our bariatric surgeons (whose surgical skills are just below that of a butcher's apprentice's blind next door neighbor). He uses 30mg BID of lovenox in fatty's. He apparently hates epidural's as well. I didn't know that until I had placed it pre-operatively (he was an hour late and I was tired of waiting on him to talk about it). I took it out in the PACU. I think in a 140kg person it would probably be safe to use low dose BID with an epidural in place but there is no evidence that I am aware of, so if something did happen you have no leg to stand on. In a small/normal sized patient I would be a little more concerned.

 

[excalibur]

2002 guidelines

http://www.ifna-int.org/ifna/e107_files/downloads/lectures/H4Neuraxial.pdf

Twice daily LMWH:
First dose should be initiated 24 hrs postiperatively.
Indwelling caterers should be REMOVED prior to the initiation of LMWH.
If a continuous technique is to be used, the catheter should be removed the next day and the FIRST dose of LMWH initiated a minimum of 2 hrs after catheter removal.

Essentially all neuraxial catheters should be removed before starting BID Lovenox and BID Lovenox should not start until 24 hrs postoperatively.

Tell the surgeon that you that you disagree with BID Lovenox with indwelling catheters as several papers show that they increase risk of epidural hematoma, and several organizations recommend against the practice. Ask him to show you some evidence to the contrary, and see what he comes up with

 

[BLADEMDA]

2002 guidelines

http://www.ifna-int.org/ifna/e107_files/downloads/lectures/H4Neuraxial.pdf

Twice daily LMWH:
First dose should be initiated 24 hrs postiperatively.
Indwellintg caterers should be REMOVED prior to the initiation of LMWH.
If a continuous technique is to be used, the catheter should be removed the next day and the FIRST dose of LMWH initiated a minimum of 2 hrs after catheter removal.

Essentially all neuraxial catheters should be removed before starting BID Lovenox and BID Lovenox should not start until 24 hrs postoperatively.

Tell the surgeon that you that you disagree with BID Lovenox with indwelling catheters as several papers show that they increase risk of epidural hematoma, and several organizations recommend against the practice. Ask him to show you some evidence to the contrary, and see what he comes up with

I agree. No epidural catheters with BID lovenox. The risk/reward curve simply isn't worth it.

 

[excalibur]

I have a patient with thoracic epidural for ivor lewis esophagectomy. Surgeon wants to use prophylactic BID lovenox, as high risk cancer patient. I told him no, but SQ heparin is ok. He states that he has been doing it at another hospital where he works (with different anesthesia group) for the last 5 years. Who is doing this?

The surgeon could use SQ heparin or once daily Lovenox with SCD's with a catheter in place

 

[excalibur]

I believe the guidlines say you can start prophylaxis dose 6 hrs after placement. Treatment dose is contraindicated.

This is for once daily dosing only. In addition for once daily dosing the second dose should be 24 hrs after first dose. So if surgeon wants to start the epidural pt on Lovenox on POD 0 like at 1800, every once daily dosing after that needs to be 1800.


Twice daily dosing is 24 hrs postiperatively for first dose and indwelling neuraxial catheters should be removed prior to first dose.

 

[TrustMe]

I feel like some of this is misleading. I think all of the literature talking about epidurals and BID lovenox is likely referring to THERAPEUTIC dosing (i.e. 1mg/kg q12hrs). The surgeon the OP is referring to is using PROPHYLACTIC dosing in a high risk patient (thus he is likely using lower dosing than recommended for therapeutic dosing but more than for normal prophylactic dosing). I am unaware of any literature supporting prophylactic dosing BID (but then again I don't read much surgical literature) such as the OP is referring or that the bariatric surgeon I encountered is using (although I don't think my guy has any literature supporting anything he does. My favorite is when this particular guy, who is also a critical care guy, has an EV-100 and an Edwards CCO swan on the same patient.). This seems like a grey area with no evidence either way.

 

[pgg]

I feel like some of this is misleading. I think all of the literature talking about epidurals and BID lovenox is likely referring to THERAPEUTIC dosing (i.e. 1mg/kg q12hrs). The surgeon the OP is referring to is using PROPHYLACTIC dosing in a high risk patient (thus he is likely using lower dosing than recommended for therapeutic dosing but more than for normal prophylactic dosing). I am unaware of any literature supporting prophylactic dosing BID (but then again I don't read much surgical literature) such as the OP is referring or that the bariatric surgeon I encountered is using (although I don't think my guy has any literature supporting anything he does. My favorite is when this particular guy, who is also a critical care guy, has an EV-100 and an Edwards CCO swan on the same patient.). This seems like a grey area with no evidence either way.

Concerning "twice daily" dosing, ASRA's admonition to not go neuraxial is presented in the context of anticoagulation for VTE prophylaxis, not treatment of existing/known DVT or PE.

http://journals.lww.com/rapm/Fullte...l_Anesthesia_in_the_Patient_Receiving.13.aspx

4.5 Postoperative LMWH
Patients with postoperative LMWH thromboprophylaxis may safely undergo single-injection and continuous catheter techniques. Management is based on total daily dose, timing of the first postoperative dose and dosing schedule (Grade 1C).

4.5.1 Twice-daily dosing. This dosage regimen is associated with an increased risk of spinal hematoma. The first dose of LMWH should be administered no earlier than 24 hrs postoperatively, regardless of anesthetic technique, and only in the presence of adequate (surgical) hemostasis. Indwelling catheters should be removed before initiation of LMWH thromboprophylaxis. If a continuous technique is selected, the epidural catheter may be left indwelling overnight, but must be removed before the first dose of LMWH. Administration of LMWH should be delayed for 2 hrs after catheter removal.

4.5.2 Single-daily dosing. The first postoperative LMWH dose should be administered 6 to 8 hrs postoperatively. The second postoperative dose should occur no sooner than 24 hrs after the first dose. Indwelling neuraxial catheters may be safely maintained. However, the catheter should be removed a minimum of 10 to 12 hrs after the last dose of LMWH. Subsequent LMWH dosing should occur a minimum of 2 hrs after catheter removal. No additional hemostasis-altering medications should be administered due to the additive effects.

I admit I haven't plowed through the 234 references they cite, but they call it 1C evidence and say it shouldn't be done (using unequivocal phrases like "must be removed"). The evidence behind the guidelines might or might not be grey, but the guideline itself isn't. It's not an area where I will push the envelope.