Epidural situation

[Idiopathic]

So, 82 year old female, status post whipple, laceration of portal vein and correction with IJ anastamosis. Patient had preop epidural placed, and now the surgeons want to let her INR "ride" so as to reduce the risk that she will clot off her portal vein graft. However, our pain service wants the INR either at or below 1.5 if the epidural is to stay in or corrected to that briefly so that the epidural can be pulled.

Who wins this battle? Do you feel comfortable leaving an epidural in place with an INR around 2.0? I personally think its okay, since Im more worried about platelet function, but Im curious to hear the more educated members of the board's opinion.

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[urge]

Pent sux tube wins.

 

[deleted126335]

.

 

[Planktonmd]

No epidural.

 

[huktonfonix]

Since the epidural has already been placed its a question of when it comes out. If its immediately postop and surgery insists on getting her therapeutic as soon as possible, then the catheter comes out sooner (probably the next morning before INR climbs ) or if theyve already started coumadin and the INR is climbing but below 1.5 then it comes out now. If its already higher than 1.5 then its gonna have to wait. Tell them to switch to heparin so you can pull the cath later.

 

[core0]

So, 82 year old female, status post whipple, laceration of portal vein and correction with IJ anastamosis. Patient had preop epidural placed, and now the surgeons want to let her INR "ride" so as to reduce the risk that she will clot off her portal vein graft. However, our pain service wants the INR either at or below 1.5 if the epidural is to stay in or corrected to that briefly so that the epidural can be pulled.

Who wins this battle? Do you feel comfortable leaving an epidural in place with an INR around 2.0? I personally think its okay, since Im more worried about platelet function, but Im curious to hear the more educated members of the board's opinion.

You could tell them that people with ESLD and high INRs still develop clots regardless of INR. On the other hand she will still bleed like stink regardless of the number because of the underlying disease (I'm assuming ESLD with a high INR).

David Carpenter, PA-C

 

[Noyac]

You could tell them that people with ESLD and high INRs still develop clots regardless of INR. On the other hand she will still bleed like stink regardless of the number because of the underlying disease (I'm assuming ESLD with a high INR).

David Carpenter, PA-C

She doesn't have ESLD. If she did I'll bet the epidural wouldn't have been placed in the first place.

 

[Noyac]

I'd leave it in if they agree to correcting the INR soon enough to pull the catheter. If not, I would pull it.

 

[coprolalia]

We pull these catheters at the end of the case. The patient gets the catheter to use as a supplement during the case, then when the case is done you squirt a little Duramorph in there (2.5 to 4 mg) and pull the damn thing.

No reason not to put an epidural in pre-op. No reason to leave it in post-op. Patients do fine. The bulk of the post-surgical pain is the incision site, and this is dramatically less problematic after 24 hours. After that, you cover with PCA.

-copro

 

[goodoc]

2.5 to 4 MG of duramorph?

 

[coprolalia]

2.5 to 4 MG of duramorph?

Yes. In the epidural space. Did I stutter?

-copro

 

[Noyac]

Nice plan Copro. But if you are pulling the cath post-op, why not just do a single shot spinal with duramorph and local? Less hassle, less risk.
Unless you are going to use the extended release Duramorph which is epidural only. I forget the name of it right now.

 

[coprolalia]

Nice plan Copro. But if you are pulling the cath post-op, why not just do a single shot spinal with duramorph and local? Less hassle, less risk.

Well, I can't take credit. Standing on the shoulders of giants, and whatnot.

But, yours is not a bad idea. I've done such a technique in kids. But, in adults, we leave the catheter in during the case. We usually run a 0.25% bupivacaine infusion during the case. You can run a very "light" general anesthetic this way, which is especially nice if you have a patient who has marginal hemodynamics (how many of such cases have you done with a vasculopath where you're fighting the BP the entire case during periods of stimulation/no stimulation?). Some of our belly cases go on for hours and hours, depending on complexity of the problem and level of surgical expertise. Have found that if you plunk in the epidural and then run an infusion at like 6-7mL/hr, you get a nice smoothe anesthetic. Patients are much more comfortable in the immediate post-op period while the Duramorph is setting up.

Unless you are going to use the extended release Duramorph which is epidural only. I forget the name of it right now.

DepoDur.

We don't use this anymore secondary to a lot of complaints of prolonged itching and potential problems related to the release system (prolonged blocks, need for extended bed rest, etc.). I'm pretty sure that this has fallen out of favor at most institutions. It's been a couple of years already since we've used this stuff.

-copro

 

[Noyac]

Yeah, I guess in residency or academics the cases may be too long for a single shot spinal. In PP you will be able to get away with it though. But I'll bet that with a GA on top of the spinal and duramorph you can easily do a 5 hr case. The spinal will have worn off but the benefits are still present and the pain is minimal. I have one orthopod that takes 5 hrs to do a total knee . F*ckin kills me. I do a single shot spinal with 250mcg duramorph and up to 15mg bupiv. I put a LMA or tube in them and they need only about 1/2 MAC gas. Wake them up and they are comfy for 1 day. The local is long gone but the duramorph is going strong.

 

[goodoc]

Nahh, you did not stutter had a senior moment and thought intrathecal for some reason, nice technique.

 

[CanGas]

This case stated the epidural was already in place and now the surgeons want to let the INR "ride" to avoid portal vein thrombosis. What do you do? The whole question of SHOULD an epidural have been placed is a whole other question and is moot at this point.

Options are:
1) Keep epidural in place, let INR ride hoping it will correct itself in 3-5 days at which time you can then remove the catheter.
2) Say screw the surgeon, risk of epidural hematoma is higher than risk of portal vein thrombosis (probably a "game over" event for this woman) and if INR is >1.5 give FFP and pull the catheter now.

As we all should know, the main risk of hematoma is upon insertion and removal of the catheter. Spontaneous hematomas 2nd to an indwelling catheter is rare.

A quick search of the literature is below:

So it looks like following liver surgery coags worsen to a peak POD 2-3 and generally return to normal POD 5. In studies using Coumadin no complications in smallish series were noted with INR's 2-3 as long as INR was normal (<1.3) when cath removed. As an aside, a question to the junior residents: why can you do a neuraxial technique on commencement of coumadin as long as INR is <1.5 but when stopping coumadin you should have INR <1.3 before doing a do a neuraxial technique?

Based on this I would leave the epidural in place and let the INR ride but it it is getting into the high 2's I would ask to have Vit K given. Goal to remove epidural by POD 5 with INR <1.3. I would not give FFP because the epidural is already in and I think the risk of vein thrombosis is much higher than the risk of epidural hematoma.

However, the points others make regarding should an epidural have been placed in the first place is a whole other issue. At my institution we no longer place epidurals for liver resections because of this issue. Not so much because of the worry about hematoma from high INR's and an in situ cath but the major hassles of having to wait 5-6 days for the INR to correct before being able to remove the cath when the patient did not need the cath beyond POD 3 which exposes them to 3 extra days of potential complications, infections, ect.

CanGas

Papers:
Postoperative coagulopathy after liver resection - Implications for epidural analgesia. 2006. Anaesthesia and Intensive Care 34 (1), pp. 118-119
- title looks good but I don't have access.

Horlocker T.T. Neurologie complications of spinal and epidural anesthesia (2000) Regional Anesthesia and Pain Medicine, 25 (1), pp. 83-98.
There were also no symptomatic spinal hematomas in 192 patients receiving postoperative epidural analgesia in conjunction with low-dose warfarin
after total knee arthroplasty. Patients received warfarin, starting on the postoperative day, to prolong the prothrombin time (PT) to 15.0 to 17.3 seconds
(normal, 10.9 to 12.8 seconds), corresponding to an international normalized ratio (INR) of 2.0 to 3.0. Epidural catheters were left indwelling 37 - 15
hours (range, 13 to 96 hours). Mean PT at the time of epidural catheter removal was 13.4 ± 2 seconds (range, 10.6 to 25.8 seconds). This study documents
the relative safety of low-dose (3 to 5 rag/d) warfarin anticoagulation in patients with an indwelling epidural catheter.

Epidural Anesthesia and Analgesia in Liver Resection. Anesth Analg 2002;95:1179-1181

+ many more. Look at the liver resection publications as there is tons of data and opinons on this situation.

 

[Bougie]

Interesting post. Any thought on tunneling these epidurals for postop pain? That way you can leave these in indefinitely and it only takes an extra minute. Anybody tunneling epidurals for these types of cases consistently?

 

[2win]

I'm with you. Leave the cath in - remove it when the INR is acceptable. The headache is coming though - see the patient, follow...bla, bla, bla. Risk and benefits - it is your call.