Epidural controversy - TID heparin - Do you do it?

[akmed07]

Please help!
At our institution we have stopped offering epidurals for post op pain for any patient who will receive heparin on tid schedule. Not a problem for most of our patients whose surgeons allow us to change the dosing to bid. Big problem for our GYN oncology patients where blood clot risk is higher.

A minority of our staff believe there should be a case-by-case review of risk and benefit and would offer epidurals to some patients receiving tid heparin. For now we offer none!

Nationally a hot topic since publication of the 2010 ASRA guidelines which state bid heparin is safe, note epidurals can be managed in patients who are fully anticoagulated on iv-heparin and report no studies on the safety of tid heparin: http://journals.lww.com/rapm/Fullte...l_Anesthesia_in_the_Patient_Receiving.13.aspx

It would be very helpful to know if
1. patients at your institution can receive an epidural if they are also receiving "Subcutaneous Heparin With Thrice-Daily Dosing"
2. your institution is participating in a study to determine the safety of epidural analgesia for tid heparin dosing.

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[2ndyear]

Big issue is removal right? Pull it before they give the first morning dose. Delay that dose if it makes you feel better.

 

[Fastrach]

Big issue is removal right? Pull it before they give the first morning dose. Delay that dose if it makes you feel better.

Agreed. Our pain team simply puts in an order to hold the morning heparin dose the day the catheter is to be pulled.

 

[seinfeld]

WTF? Has no one at the institution placed an epidural for an AAA where during the case you give 10,000+ iv heparin.

BID heparin is worthless
Have them schedule the Heparin q8h instead of TID (there is an actual difference) once you wait your 4 hours post last dose then just right an order when the next subsequent dose can be given.

It would be a shame to not offer such a pain reliever due to inflexibility on the anesthesia and surgical sides

 

[Noyac]

Or you could just do intrathecal morphine.

 

[dhb]

Or just use LMWH. Heparin TID is a little third worldish imho

 

[lobelsteve]

Or just use LMWH. Heparin TID is a little third worldish imho

Cost issues more likely than the clinical benefit.

 

[Noyac]

Or just use LMWH. Heparin TID is a little third worldish imho

agreed. I haven't seen this practice in years.

Wasn't LMWH shown to be better care? Dare I say SOC?

 

[dhb]

Dare I say SOC?

 

[Sergio99]

agreed. I haven't seen this practice in years.

Wasn't LMWH shown to be better care? Dare I say SOC?

Hello,

I agree with Noyac and dhb. I haven't seen it either, but if the surgeon wants it, you cannot convince him not to use it. Internists are usually more flexible. I routinely write orders to check coags daily while the epidural is in and hold the LMWH for 12 hrs before the expected time of removal. Then I tell them when they can restart it. Any other anticoagulants while the epidural is in are strictly forbidden without asking me first.

Greetings

 

[Noyac]

Hello,

I agree with Noyac and dhb. I haven't seen it either, but if the surgeon wants it, you cannot convince him not to use it. Internists are usually more flexible. I routinely write orders to check coags daily while the epidural is in and hold the LMWH for 12 hrs before the expected time of removal. Then I tell them when they can restart it. Any other anticoagulants while the epidural is in are strictly forbidden without asking me first.

Greetings

YOu ever had a pt accidentally DC his epidural while getting out of bed and still on LMWH?