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[jetproppilot]

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62 year old female h/o HTN, PVD, pulmonary fibrosis with room air sat 89-90%.

Arrives in day surgery for a fem-pop, scheduled for GA.

Assume she is medically optimized, and she needs the operation.

My partner sees her, determines she'd benefit from an epidural anesthetic.

The cardio-vascular surgeon doing the case, new to our facility, says he wants all his fem-pops put to sleep, no matter what.

Says putting in an epidural is risky since heparinization is gonna take place.

Whatcha do now?

Not looking for how to flame the surgeon. Looking for literature based opinions here.

BTW, surgeon not being a d ick about his request. For whatever reason he is steadfast about his request.

Any literature supporting regional in this clinical scenerio?

 

[ultm8frisbee]

62 year old female h/o HTN, PVD, pulmonary fibrosis with room air sat 89-90%.

Arrives in day surgery for a fem-pop, scheduled for GA.

Assume she is medically optimized, and she needs the operation.

My partner sees her, determines she'd benefit from an epidural anesthetic.

The cardio-vascular surgeon doing the case, new to our facility, says he wants all his fem-pops put to sleep, no matter what.

Says putting in an epidural is risky since heparinization is gonna take place.

Whatcha do now?

Not looking for how to flame the surgeon. Looking for literature based opinions here.

BTW, surgeon not being a d ick about his request. For whatever reason he is steadfast about his request.

Any literature supporting regional in this clinical scenerio?

MSIV, so be kind.
Assuming that the patient is not being anticoagulated because of her surgery, I vaguely remember running into this similar situation. We went ahead and did the epidural. I can't give you any literature to back this up, but I believe that introperative heparinization is not a contrainindication for an epidural. The epidural should actually help distal blood flow in the lower extremeties as well.

 

[bullard]

I assume you mean literature besides the ASRA guidelines that were posted on another thread. The following was found on scholar.google.com using "epidural anesthesia heparinization" as search terms.

Anesth Analg 2001;93:528-535

A Prospective Randomized Study of the Potential Benefits of Thoracic Epidural Anesthesia and Analgesia in Patients Undergoing Coronary Artery Bypass Grafting

We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (gen- eral anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded—eight in Group TEA and four in Group GA—because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.

IMPLICATIONS: Many anesthesiologists believe that thoracic epidural anesthesia/analgesia (TEA) is contraindicated for cardiac surgery because of increased risk of paraplegia. However, this large prospective study confirms that perioperative morbidity is significantly less with TEA and suggests that the practical benefits may outweigh the unquantified risk of epidural hematoma.

 

[The_Sensei]

62 year old female h/o HTN, PVD, pulmonary fibrosis with room air sat 89-90%.

Arrives in day surgery for a fem-pop, scheduled for GA.

Assume she is medically optimized, and she needs the operation.

My partner sees her, determines she'd benefit from an epidural anesthetic.

The cardio-vascular surgeon doing the case, new to our facility, says he wants all his fem-pops put to sleep, no matter what.

Says putting in an epidural is risky since heparinization is gonna take place.

Whatcha do now?

Not looking for how to flame the surgeon. Looking for literature based opinions here.

BTW, surgeon not being a d ick about his request. For whatever reason he is steadfast about his request.

Any literature supporting regional in this clinical scenerio?

I'd have no problem putting her to sleep just to keep the peace. Don't see any contraindications to doing so.......

 

[ultm8frisbee]

Some Literature:

Regional Anesthesia in the Anticoagulated Patient - Defining the Risks
Published by the American Society of Regional Anesthesia and Pain Medicine

Combining neuraxial techniques with intraoperative anticoagulation with heparin during vascular surgery seems acceptable with the following cautions:
a. Avoid the technique in patients with other coagulopathies.
b. Heparin administration should be delayed for 1 hour after needle placement.
c. Indwelling neuraxial catheters should be removed 2-4 hours after the last heparin dose and the patient's coagulation status is evaluated; re-heparinization should occur one hour after catheter removal.
d. Monitor the patient postoperatively to provide early detection of motor blockade and consider use of minimal concentration of local anesthetics to enhance the early detection of a spinal hematoma.
e. Although the occurrence of a bloody or difficult neuraxial needle placement may increase risk, there are no data to support mandatory cancellation of a case. Direct communication with the surgeon and a specific risk-benefit decision about proceeding in each case is warranted.

 

[militarymd]

I hate trying to change a surgeons' mind....I'd put the patient to sleep.....


Other than some stuff from Hopkins that showed improved graft patency...there is no benefit to putting in an epidural.

 

[jetproppilot]

62 year old female h/o HTN, PVD, pulmonary fibrosis with room air sat 89-90%.

Arrives in day surgery for a fem-pop, scheduled for GA.

Assume she is medically optimized, and she needs the operation.

My partner sees her, determines she'd benefit from an epidural anesthetic.

The cardio-vascular surgeon doing the case, new to our facility, says he wants all his fem-pops put to sleep, no matter what.

Says putting in an epidural is risky since heparinization is gonna take place.

Whatcha do now?

Not looking for how to flame the surgeon. Looking for literature based opinions here.

BTW, surgeon not being a d ick about his request. For whatever reason he is steadfast about his request.

Any literature supporting regional in this clinical scenerio?

My partner ended up doing the epidural...most surgeons we work with defer the anesthesia decisions to us so we were surprised when surgeon dude said he wanted all his patients put to sleep, regardless of anything.

I know the study's results and conclusions.

Still hard for me to convince myself that I can intubate a lady like this and end up with the same result as a regional technique where we dont intrude on her pulmonary system with intubation, the potential to not be able to extubate with prolonged ventilation in the ICU, resultant exposure to iatrogenic pulmonary infection because of the (potential) necessary ventilation in the ICU, physiologic stress induced by the endotracheal tube, etc etc

 

[jetproppilot]

My partner ended up doing the epidural...most surgeons we work with defer the anesthesia decisions to us so we were surprised when surgeon dude said he wanted all his patients put to sleep, regardless of anything.

I know the study's results and conclusions.

Still hard for me to convince myself that I can intubate a lady like this and end up with the same result as a regional technique where we dont intrude on her pulmonary system with intubation, the potential to not be able to extubate with prolonged ventilation in the ICU, resultant exposure to iatrogenic pulmonary infection because of the (potential) necessary ventilation in the ICU, physiologic stress induced by the endotracheal tube, etc etc

She did fine by the way.

 

[vegas]

With the surgeon being steadfast on GA, what kind of convincing did your partner do for the surgeon to opt. for regional?

 

[jetproppilot]

With the surgeon being steadfast on GA, what kind of convincing did your partner do for the surgeon to opt. for regional?

None. He did his thing, went in the room, called the surgeon to tell him they were ready for him, surgeon walks in, etc etc.

Again, surgeon wasnt a d ick. Said he'd be willing to look at literature, discuss with us, etc but barring any significant advantages, he prefers GA.

Hard to argue with, so I guess I'll be making Mil, the president of the NRAA (Non Regional Anesthesiologists of America) happy by snorkeling all his patients.

 

[Noyac]

62 year old female h/o HTN, PVD, pulmonary fibrosis with room air sat 89-90%.

Arrives in day surgery for a fem-pop, scheduled for GA.

Assume she is medically optimized, and she needs the operation.

My partner sees her, determines she'd benefit from an epidural anesthetic.

The cardio-vascular surgeon doing the case, new to our facility, says he wants all his fem-pops put to sleep, no matter what.

Says putting in an epidural is risky since heparinization is gonna take place.

Whatcha do now?

Not looking for how to flame the surgeon. Looking for literature based opinions here.

BTW, surgeon not being a d ick about his request. For whatever reason he is steadfast about his request.

Any literature supporting regional in this clinical scenerio?

A meta-analysis of 141 randomized trials comparing neuraxial analgesia with general for all types of pts. has recently shown significant reductions in perioperative death, pneumonia, and resp. depression due to neuraxial technique. It appeared that both thoracic epidural and spinal anesthesia were assoc'd with decreased risk of death but not lumbar epidural. Since thoracic epi's are not adequate for lower ext. vascular grafting, spinals are the only neuraxials that would qualify. However, nonfatal perioperative morbidities like MI, perioperative and postoperative bleeding requiring transfusion, pneumonia, resp depression and renal failure were reduced for pts randomized to any form of neuraxial block. But because these stidies looked at multiple surgical populations, the authors were unable to show statistical significance.

2 studies: Christopherson et al, comparing epidural vs general for lower ext grafts, and Tuman et al comparing epidural supplemented with general for aortic aor lower ext vasc surgery, showed that graft failure was lessened with epidural when the epidural was continued post-op.
Then there is the study by Pierce et al that showed no difference in in rate of post-op amputation b/w spinal and general. Spinals are not continued beyond surgery as epidurals are therefore supporting post-op epidural.

Therefore there is suggestive evidence that epidurals continued into the post-op period may give some benefit as to graft patency however, anticoagulation plays a big part in this.

Also, there are some studies that suggest that general anesthesia with PAC maintaining high C.O. in the post-op period and/or aggressive anticoagulation may be just as beneficial.