epidural catheters

[PinchandBurn]

Ladies/Gents-

what's the general consensus in regards to keep epidural catheters when LMWH is going to be used. We are trying to establish some some guidelines at our hospital.

Can epidural be placed IF you know ahead of time heparin and LMWH will be used.

If an epidural was placed, my understanding from the ASRA guidelines is:
1) if high dose LMWH (1.5mg/kg) or 0.5mg BID is used then you have to wait 24 hours (for high dose) and 12 hours (for BID) since the last administration before removing the catheter. Then only give the next dose of said LMWH after 2 hours.

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[psychbender]

We keep epidural and peripheral catheters in patients on lovenox regularly. If an epidural is in place, we tell the surgeons to change from 30mg BID to 40mg daily, and try to get the nurses to give it in the evening (1800-2100). That way, if we have to replace/remove the epidural in the morning (before yet another trip to the OR), they should be >10-12 hours since last dose, and their DOS dose will be several hours after the procedure. This way, lovenox is not held, and they don't miss any doses. If we know that they want to give lovenox in the OR, then we try to get the pt down early, get the epidural in, and have the intraop anesthesiologist give the lovenox after two hours have elapsed.

If we pull a catheter, we pull it after >10-12 hours since last dose, and tell the nurse to hold the next dose for 1-2 hours. If we have someone on weight-based (1mg/kg) lovenox, then no neuraxial, but we will continue a peripheral nerve catheter (a few intrepid staff may have us place a catheter while the pt is on BID weight-based lovenox, if 12 hours out from last dose, and if the need is great), and when it needs to come out, take it out 12 hours after the last dose, and hold the next dose for 2 hours.

 

[Idiopathic]

we ask that they be off lovenox while the epidural is in place and they can restart it after 2 hours.

 

[Noyac]

The ASRA guidelines spell it out pretty damn clearly.

 

[PinchandBurn]

The ASRA guidelines spell it out pretty damn clearly.

that's what I thought too.

But look above at Idiopathic's response. It seems at some institutions lovenox is completely held/not given if an epidural is in place.

My personally understanding is c/w Psychbender's........

 

[Mr Wizard]

ASRAs recent consensus statement still leaves the post-op LMWH VTE ppx and epidurals up to some interpretation which is why there are a good number of institutions that allow no indwelling catheters and use of LMWH until the 10-12hrs after catheter removal.

I think a lot of the cautiousness is due to the prolonged altered coagulation and inability to quanitfy bleeding risk or reverse LMWH coupled with the ever increasing medical complexity of inpatients today. There still needs to be continued aggregation of risk data to further delineate clinical risk. ASRAs recommendations have become more stringent with regards to LMWH which may well continue, so a lot of institutions have collaborated with our surgical colleagues and offered UFH use with indwelling catheters that transition to LMW once it is removed.