epidural asleep, would you do it?

[achieman]

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trauma patient been in the ICU for several days, intubated with multiple lower extremity/hip fractures, on fondaparinux (off for 24h). PT/INR/PTT 15/1.3/30. Underwent multiple fixation of lower extremities and hip, 1L blood loss, transfused 3 cell, 1 ffp, surgeon request epidural at the end of case since pt already lateral and want to extubate in the next 12 hours. Resent labs at the end of the case, all same as before, INR 1.3, nl platelets, fibrinogen.

who would do the epidural and who wouldn't, and why?

 

[drccw]

if you think an epidural would help this guy then yeah I would do it; asleep.... lumbar right? Not a huge deal- coags were fine... one issue would be consent- if I had had prior consent or consent from NOK then I would do it... i have no qualms about performing a lumbar epidural on someone asleep.. thoracic yes (I've done it...) but lumbar... no qualms... ever put in a lumbar drain? 14G tuohy needle. drive it straight back.... gushing CSF....

but this gets into a bigger question- would regional analgesia help this guy? is it going to help you extubate him? lower extremity? I doubt there is a ton of benefit....

 

[Planktonmd]

trauma patient been in the ICU for several days, intubated with multiple lower extremity/hip fractures, on fondaparinux (off for 24h). PT/INR/PTT 15/1.3/30. Underwent multiple fixation of lower extremities and hip, 1L blood loss, transfused 3 cell, 1 ffp, surgeon request epidural at the end of case since pt already lateral and want to extubate in the next 12 hours. Resent labs at the end of the case, all same as before, INR 1.3, nl platelets, fibrinogen.

who would do the epidural and who wouldn't, and why?

If I was a resident working under someone else's license I would be glad to do it if instructed to do so.
Under my license the answer is no.
You always have to think about what the "experts" are going to say if the patient ends up with a nerve root injury.

 

[Consigliere]

Wouldn't do it.

 

[jwk]

Would never be done here either.

 

[Noyac]

Nope

 

[Masseter Spasm]

I often place epidurals under GA in pediatric patients (ranging in age from infant-adolescent). There is literature to support the safety of this practice. In fact at many pediatric centers, some practioners actually feel "weird" when they have to place an epidural in an awake patient.

I think placing a (thoracic) epidural in an adult trauma patient with rib fractures to expedite weaning from the vent is a practice with an acceptable risk to benefit ratio. Placing a lumbar epidural for a patient with LE fractures, however, does not strike me as a high yield indication. (A possible exception would be if the patient is a pulmonary cripple.)

 

[CambieMD]

An awake patient is a valuable monitor. They can tell you if your catheter is in the wrong place or if you are on the verge of causing serious nerve damage or worse.
I say no. How can I defend myself if something goes wrong.

Cambie

 

[Fooper]

No thanks....in addition to the above concerns, any subsequent neuro deficits related to the trauma could be attributed to your epidural

 

[Noyac]

A recent publication has reviewed some current controversies in pediatric regional anesthesia and highlighted differences from adult practice. In adults, performing nerve or neuraxial blocks under general anesthesia is strongly discouraged because of the risks of nerve or spinal cord injuries. In children, however, it is common practice to perform these blocks under a general anesthetic. One recent study prospectively looked at 24,000 regional blocks performed in children under general anesthesia. Twenty-three adverse events were reported, all of them minor and without lasting sequelae. A similar study conducted in awake adults reported a similar rate of complications, but their severity was much greater, resulting in deaths and permanent neurologic damage. The author points out that there is generally no compelling reason to perform blocks under general anesthesia except in children, where sudden unexpected movement might be hazardous.

This is a direct quote from my CME course (SEE through the ASA) w/c I read today. Take it for what it is worth.

 

[urge]

I wouldn't do it. Not because the pt is asleep or not. I have a few issues:
1 was pt consented for it?
2 is there any known deficit?
3 if the surgeon wanted one, why after surgery is done? Why not before?

 

[bubalus]

Not worth the risk to do it on an anesthetized patient.

What about the fondaparinux? Would anyone not place the epidural in this patient if he or she were awake?

 

[Noyac]

What about the fondaparinux? Would anyone not place the epidural in this patient if he or she were awake?

The ASA and ASRA are very clear on this.

 

[bubalus]

I'm familiar with the guidelines. I brought up that question more rhetorically because I thought it was interesting that everybody seemed to key on on the asleep placement, but there wasn't much discussion on the fondaparinux. Maybe I'm misreading the statements or maybe I'm a chicken, but the fondaparinux is as big a deal for me as the asleep placement.

ASRA's statement is:

"Fondaparinux produces its antithrombotic effect through factor Xa inhibition. The FDA released fondaparinux with a black box warning similar to that of the LMWHs and heparinoids. The actual risk of spinal hematoma with fondaparinux is unknown. Consensus statements are based on the sustained and irreversible antithrombotic effect, early postoperative dosing, and the spinal hematoma reported during initial clinical trials. Close monitoring of the surgical literature for risk factors associated with surgical bleeding may be helpful in risk assessment and patient management.

Until further clinical experience is available, performance of neuraxial techniques should occur under conditions utilized in clinical trials (single needle pass, atraumatic needle placement, avoidance of indwelling neuraxial catheters). If this is not feasible, an alternate method of prophylaxis should be considered." (emphasis added)

From the ASA May 2005 Newsletter

"Fondaparinux is now recommended as an antithrombotic agent following major orthopedic surgery. The extended half-life (approximately 20 hours) allows once-daily dosing, which also impedes safe catheter removal. Both the American Society of Regional Anesthesia and Pain Medicine (ASRA) and ACCP recommend against the use of fondaparinux in the presence of an indwelling epidural catheter."

In this patient, I'd say no on the epidural, both for the risk of placing it in an anesthestized patient, but also because of the fondaparinux. It's clear from their statement that indwelling catheters should be avoided while on fondaparinux. I'm reasonably good with my hands, but I won't guarantee a single pass, and I've seen those who are better than I am struggle occasionally too. What the guidelines don't address is timing, and that's one of the issues in this case. How long should I wait after discontinuing fondaparinux until I could place an epidural safely? One half life? Two? Three? Four? The guidelines don't really address that. I know what I'd say based on my understanding on pharmacokinetics, but that might not be everyone's answer.