pradaxa and total hip, labs?

[GaseousClay]

pt on pradaxa was told to stop 5 days prior to revision hip. INR/PTT 2 weeks prior at 1.6/65 respectively. Would you get repeat coags day of surgery even tho normally no lab testing required for pradaxa (correlation to bleeding effect is questionable also) and it was stopped 5 days ago?

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[Arch Guillotti]

No.

 

[BLADEMDA]

 

[BLADEMDA]

pt on pradaxa was told to stop 5 days prior to revision hip. INR/PTT 2 weeks prior at 1.6/65 respectively. Would you get repeat coags day of surgery even tho normally no lab testing required for pradaxa (correlation to bleeding effect is questionable also) and it was stopped 5 days ago?

5 days is fine for the surgery but I wouldn't choose a Neuraxial technique. Instead, GA with ETT +/- an arterial line and good IV access (revision hip). I don't think additional labs are indicated but if you want them then order after the case is underway IMHO.

 

[BLADEMDA]

Take a look at the 1/2 life of Pradaxa which is about 17 hours. You must also take into account Cr Clearance but 5 days would be fine to proceed with the surgery.

 

[BLADEMDA]

I'm very conservative with Neuraxial anesthesia when patients are on anticoagulants; I see little reason to push the envelope when the complication of an epidural hematoma is devastating to the patient. Many patients are older with some degree of renal insufficiency making the 4 half life rule insufficient to perform neuraxial anesthesia.

https://depts.washington.edu/anticoag/home/sites/default/files/Neuraxial Guidelines_1.pdf

 

[facted]

pt on pradaxa was told to stop 5 days prior to revision hip. INR/PTT 2 weeks prior at 1.6/65 respectively. Would you get repeat coags day of surgery even tho normally no lab testing required for pradaxa (correlation to bleeding effect is questionable also) and it was stopped 5 days ago?

5 days is fine but you should document normal coags before neuraxial. I would recheck coags and if normal, proceed with neuraxial.

 

[dchz]

Excellent post as always Blade.

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

But let me pose the question: How many of yall out there in private practice would do this case if the pt was off it for 3 days with normal CrCl? (assume no neuroaxial and just do GA w/ ETT A line)
72hrs = 4.6 Half lives.

 

[psychbender]

Excellent post as always Blade.

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

But let me pose the question: How many of yall out there in private practice would do this case if the pt was off it for 3 days with normal CrCl? (assume no neuroaxial and just do GA w/ ETT A line)
72hrs = 4.6 Half lives.

As with everything, it depends. I'd tell the surgeon he's going to deal with a lot more bleeding than usual, and weigh the risks as they pertain to that specific patient. If otherwise mostly healthy (why is he on pradaxa, anyway?), with a good starting Hct, I'm fine with proceeding, after discussing the increased likelihood of transfusion with the patient. Likely, the surgeon will cancel when you tell him there will be more bleeding and a higher probability of post-op complications, compared to if he just waited a few more days. He's not getting a neuraxial.

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[dhb]

48h if normal renal fct

 

[BLADEMDA]

Excellent post as always Blade.

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

But let me pose the question: How many of yall out there in private practice would do this case if the pt was off it for 3 days with normal CrCl? (assume no neuroaxial and just do GA w/ ETT A line)
72hrs = 4.6 Half lives.

Yes, I'd do the case as long as the patient was off Pradaxa for 72 hours under GA with ETT. I'd likely cancel if the patient was off the drug for only 48 hours. This assumes normal renal function and normal Hgb/Hct.

 

[anbuitachi]

No would not repeat labs. Dont think A line is neccessary either unless it's a complicated hip. No neuraxial unless confirmation w repeat labs. Give TXA to help a little w bleeding

 

[facted]

Excellent post as always Blade.

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

But let me pose the question: How many of yall out there in private practice would do this case if the pt was off it for 3 days with normal CrCl? (assume no neuroaxial and just do GA w/ ETT A line)
72hrs = 4.6 Half lives.

The board answer is definitely NOT 7 days. It's 5 days currently for NEURAXIAL anesthesia per the ASRA guidelines (Anticoagulation 3rd Edition), though there's limited data here, so you could make an argument for longer. But that's for neuraxial anesthesia...for doing the case, I DEFINITELY wouldn't wait 7 days even with crappy renal function.

This case should be done in private practice and academic medical setting without issue.

If the patient has been off for a solid 5 days, repeat the labs and if coags are normal, I would personally place a spinal. For starters, spinal anesthesia for total joints has been decisively shown to reduce EBL in the perioperative period (among many other benefits). TXA is a no-brainer (we give it for all total joints where it's not contraindicated).

But if you're really worried about the spinal hematoma risk, do the case under GA, and there's no reason then to repeat coags.

But in my opinion, even with elevated coags, off pradaxa for 5 days, there's no reason to cancel this case.

 

[BLADEMDA]

Excellent post as always Blade.

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

But let me pose the question: How many of yall out there in private practice would do this case if the pt was off it for 3 days with normal CrCl? (assume no neuroaxial and just do GA w/ ETT A line)
72hrs = 4.6 Half lives.

The T1/2 of dabigatran (12–15 hours in healthy patients) suggests an interval of 34 hours between last dose and catheter manipulation/withdrawal, but analgesic catheters are not recommended. ASRA Anticoagulation (third edition) interim update and the published consensus by ASRA, ESRA, and World Institute of Pain suggests waiting 4–5 days (5 − T1/2) from last administration before performing RA, 6 hours to initiate medication post-RA and 6 hours between removal of neuraxial catheter and next dose.4,19,32

Waiting 5 days prior to Neuraxial anesthesia is the correct board answer. Of course, if the patient had chronic kidney disease and reduced Cr Cl you could argue that 5 days isn't long enough but even then the data seems to still support 5 days. 3 days off Pradaxa should be long enough to proceed with the case under GA with ETT. Most likely, even neuraxial anesthesia (single shot SAB with non cutting needle) would be safe if the patient had completely normal renal function.

I'm pretty conservative these days with performing Neuraxial anesthesia on patients who have taken the newer anti-coagulants so I tend to want a "buffer" in terms of time off the drug.

I see a lot more Eliquis and Xarelto than Pradaxa these days.
https://kr.ihc.com/ext/Dcmnt?ncid=520499512&tfrm=default

 

[fakin' the funk]

I'm a Ca-1 right now, I often over hear "if this is Private practice this case would be done".

Obv the oral board answer is 7 days.

It's not 7 days. It's 3-5 days. No idea where the Stanford guidelines get that from. I routinely refer to the UW guidelines btw. I would do it at 72 hours. Revision hip doesn't need art line (???), just one good IV.

 

[deleted162650]

It's not 7 days. It's 3-5 days. No idea where the Stanford guidelines get that from.

They're just coasting on their reputation.

 

[stonemd]

ASRA Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant

* We recommend a 5 half-life interval between discontinuation of dabigatran and medium- or high-risk pain procedure. This corresponds to 4 to 5 days.

* For low-risk procedures, a shared assessment, risk stratification, and management decision in conjunction with the treating physician(s) should guide whether dabigatran should be stopped. A 2 half-life interval may be considered.

* For patients with end-stage renal disease, we recommend a 6-day interval because the half-life of dabigatran increases to 28 hours in this condition.

* We recommend a 24-hour interval after interventional pain procedures before resumption of dabigatran.

* If the risk of VTE is very high, dabigatran may be given 12 hours after the pain intervention. The decision regarding timing of drug resumption should be shared with the patient’s treating physician(s).