Epidural and Plavix

[FutureDoc79]

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Hello, I dont usually post, but I had an issue today and I want some ideas from all you experts out there. I had a scheduled thoracotomy for empyema decortication today. Pt with history of cardiac stents in 12/2007 and been taking plavix. Upon interview with pt yesterday and this AM, pt states plavix was stopped at his last cardio appt on 5/14/08. Proceeded with thoracic Epidural (T5-6) Placement was atraumatic with catheter advanced without incident. When speaking to surg resident during closure he mentions that he will hold the plavix......I said he has not been on plavix, which appearently was wrong. So, upon admission to hospital, plavix therapy was re-started by the ER and the patient had been taking plavix for the 4 days. Both myself and my attending missed this, there is no excuse for this, however, it is done. We are not using the catheter as we do not want to mask any signs of hematoma and have d/c the plavix for now. Pt is getting neuro checks q 1 hour tonight. Any input on when to remove the cath? Thanks for your input Doc79

 

[Planktonmd]

Hello, I dont usually post, but I had an issue today and I want some ideas from all you experts out there. I had a scheduled thoracotomy for empyema decortication today. Pt with history of cardiac stents in 12/2007 and been taking plavix. Upon interview with pt yesterday and this AM, pt states plavix was stopped at his last cardio appt on 5/14/08. Proceeded with thoracic Epidural (T5-6) Placement was atraumatic with catheter advanced without incident. When speaking to surg resident during closure he mentions that he will hold the plavix......I said he has not been on plavix, which appearently was wrong. So, upon admission to hospital, plavix therapy was re-started by the ER and the patient had been taking plavix for the 4 days. Both myself and my attending missed this, there is no excuse for this, however, it is done. We are not using the catheter as we do not want to mask any signs of hematoma and have d/c the plavix for now. Pt is getting neuro checks q 1 hour tonight. Any input on when to remove the cath? Thanks for your input Doc79

I would never put an epidural in a patient that has an empyema, you guys are brave.
On the other hand the plavix is restarted and you already have an epidural in so I say: give morphine 4-5 mg through the epidural then take it out now.
Watch the patient for 24 hours, most likely nothing is going to happen.

 

[FutureDoc79]

It was boarded as a VATS with pleural effusion evacuation/pleuridesis and possible thoracotomy......Made the incision and saw pus, converted to thoracotomy.........Thanks for the reply

 

[lobelsteve]

7 days off Plavix to do the epidural (little oops if no hematoma develops, bigger oops if hematoma develops and surgical decompression needed).

7 days off of Plavix to remove the catheter.

The risk exists with placing the epidural and removing the catheter. The risk for an indwelling catheter, stimulator lead is minimal as long as it is not being manipulated.

 

[urge]

You probably have to check for more than 24 hrs. Hematomas develop on the 3rd day and sometimes later. Safest thing to do is leave it in for week and then pull it out. It's best if you get cardiology on board in case the stent thromboses. You can also bite the bullet and pull it now continuing the neurochecks.

 

[Noyac]

Well on to my soap box. These stents are about 5 months old. Are they DES? Where were they placed? How much myocardium is at risk if they thrombose? I'd probably bridge a high risk stent with ASA at least while I waited for the plavix window. If it is a lower risk stent then I don't know, maybe I wouldn't give anything and wait to pull the epidural.

You could also transfuse with some good platelets, pull the epidural and then restart the plavix after a safe amount of time. But this may be a little extreme.

 

[CerebralEdema]

Wow, what a tough situation.... I too would be very nervous about placing an epidural in the setting of empyema and risk of transmitted infection.

Here are my 2 cents. I have been in a similar situation. I placed a thoracic epidural in a patient undergoing a thoracotomy for tumor resection who had a drug-eluding stent placed 12 months ago. Plavix was mistakenly restarted on POD 1 by the surgical house staff. After much discussion with my collegues we went ahead and removed the cathether about 6 hours after the Plavix dose was taken and watched him in the ICU with Q2 hour neurochecks for 48 hours. This is a risky move, most hardcore conservatives would probably say to hold the Plavix and keep the catheter in for 7 days. They would also disagree with giving fresh platelets and then pulling the catheter because (1) you introduce the chance for bloodborne infection and (2) the new platelets are being given into an environment that is still rich with clopidogrel and they too will have irreversibe blockade of the ADP receptor.

I don't know what the "right answer" really is, but as long as you know to look for the signs of hematoma carefully and consult neurosurg and get an MRI immediately if there is concern then you are doing the right thing in a bad situation.

 

[Noyac]

I don't have any problem placing an epidural in someone with an empyema as long as that person is being treated effectively with IV antibiotics.

As far as risk of plt transfusion risks. You run them in and pull the catheter. Don't give them time to be inactivated. Drastic but if you need to do something, this is an option. Blood Borne infections are very very rare.

 

[maximuum]

We actually had an M&M about this, a very similar situation where the epidural was placed after it was established the patient was on Plavix. Apparently, the risk of epidural hematoma when a patient is on Plavix is only 1:2000. For the patient at our institution, the epidural was kept in place (may as well use it while it is there) and removed 7 days later after the patient stopped taking his aspirin. I think the risk of epidural hematoma is much lower than thought in this situation, however, if he doesn't walk out of the hospital you would be feeling terrible.

 

[DreamMachine]

.

 

[Planktonmd]

I don't have any problem placing an epidural in someone with an empyema as long as that person is being treated effectively with IV antibiotics.

The anatomical proximity of the pleural space and the paravetebral space makes me uncomfortable placing a thoracic epidural in a patient that has a pleural space full of pus even if they are receiving antibiotics.
The infection is just too close to where I am about to insert an indwelling catheter.

 

[deleted126335]

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[lobelsteve]

The anatomical proximity of the pleural space and the paravetebral space makes me uncomfortable placing a thoracic epidural in a patient that has a pleural space full of pus even if they are receiving antibiotics.
The infection is just too close to where I am about to insert an indwelling catheter.

We run into this problem with severely degenerative spines. I've come in at
L5-S1 and snaked a catheter up to C4 (really just to see if I could avoid doing 2 separate procedures for separate diagnoses), but the same would apply.

 

[Noyac]

The anatomical proximity of the pleural space and the paravetebral space makes me uncomfortable placing a thoracic epidural in a patient that has a pleural space full of pus even if they are receiving antibiotics.
The infection is just too close to where I am about to insert an indwelling catheter.

I understand your concern.

 

[coprolalia]

What about the safety of leaving a catheter in for 7 days in an empyema patient? 😱 Talk about a nidus!

-copro

 

[mille125]

wow....tough case...


in all likelihood no adverse effects are going to happen no matter what you do


I think that personally I would take the conservative view and leave the catheter in for seven days while holding plavix. Consulting neurosurgery and cardiology is prudent. If something does happen (epidural hematoma or abscess), I would want neurosurgery to be familiar with the case because this could get very ugly very fast.


I actually practice pain management. This is an issue that I often face. I have trained my staff to record blood thinners (ie plavix, coumadin, ticlid, etc) in bold on the patient's chart. I ask all of my patients questions about blood thinners prior to procedures. With all of this said, there was one case last week where a patient was started on ticlid between the time of me scheduling the case and the patient showing up for the procedure. A very astute preop nurse picked this up. The reason that this happened is because I gave an inservice to the ambulatory staff on the dangers of blood thinners plus epidurals. I am saying all of this to encourage you and your attending to talk with the medical and nursing staff involved to figure out how to avoid this in the future. Unfortuately, many things are done on the floor without the knowledge of the anesthesiologist. Although you are ultimately responsible, this is a breakdown in communication that needs to be addressed. Thoracic epidural is a very common procedure in this arena. You may want to talk to the nursing staff and come up with some sort of system so that you can "flag" these patients and prevent a repeat scenario.


In the end your patient will probably do well.

 

[FutureDoc79]

First, thanks for all of the helpful information on this subject. After discussing with my attending, we formulated a plan last week. I maintained the Neuro checks q 1 hour for 48 hours, then switched to q3 hours until this AM. Cardiology was on the case and wanted to continue plavix, but was in agreement with holding it until today( 6 days held) to facilitate the catheter removal. There was not any change in his neuro status throughout the weekend. In fact when I saw him this AM, he was up walking around the room and feeling good. I never used the catheter, had it secured and sealed under a op-site. We removed the catheter this afternoon. Site was clean, and without infection. Neuro checks q 1 hour overnight and start back on plavix in the morning. After all this, I am glad we took the conservative approach and maintained the catheter. Thanks again Doc79