Who here holds off on doing regional/neuroaxial anesthesia for patients who are on DVT prophylaxis Heparin (5k Units SQ bid)? We're talking about otherwise healthy patients who are on nothing else that affects their coagulation status....
SC Heparin & Regional Anesthesia
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I'm interested in this, too. I had problems in the past with anesthesia trying to d/c my Lovenox orders on patients with epidurals. For a while there, we just stopped using them, but now surgery and anesthesia have come to the agreement that the Heparin just needs to be held prior to removing the epidural (8 hours for SQ heparin, 12 hours for Lovenox).
Is there any evidence in the anesthesia literature regarding prophylactic Lovenox and epidural hematoma rates? I've tried searching before and didn't find much. What are the practices in your hospitals? Proman?
On a side note, Heparin 5,000 units SQ q12 hours is probably inadequate chemoprophylaxis. I still see it from time to time, but I think there's been a few studies that support a q8 hour regimen.
I do not hold regional anesthesia for patients who are taking SQ 5k bid Heparin. On the other hand, I do hold for Lovenox. That's per ASRA. Most anesthesiologists would agree on holding off for the Lovenox patients, I just have seen some variability--with little evidence--with regards to patients on SC heparin prophylaxis. I'm obviously talking about otherwise healthy patients, who have no other risk factors from a coagulation point of view....
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http://journals.lww.com/rapm/Fullte...l_Anesthesia_in_the_Patient_Receiving.13.aspx
recent release of asra guidlines, I think it was Jan of 2010
recent release of asra guidlines, I think it was Jan of 2010
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From the link Bostonblaz posted (ASRA 2010 guidelines)
page 10 unfractionated heparin
3.2 no contraindication for neuraxial with 5000 units UFH bid SQ. Risk may be reduced by delaying heparin injection until after block is placed.
3.3 safety of TID dosing not established
page 13 LMWH
4.3 presence of blood during needle and catheter placement does not need to delay surgery
4.4.1 preop prophylaxis LMWH: needle placement should be 10-12 hours after last dose
4.4.2 treatment LMWH: should wait 24 hours after last dose
4.4.3 preop prophylaxis within 2 hours: no neuraxial technique recommended.
Postop LMWH
4.5.1 BID dosing: first dose should be administered no earlier than 24 hours, regardless of anesthetic technique. Catheters should be removed before initiation. LMWH should be delayed 2 hours after the catheter was removed.
4.5.2 Daily dosing: first dose should be administered 6-8 hours postop. Second dose should occur no earlier than 24 hours after the first dose. Catheters may be used but should be removed a minimum of 10-12 hours after the last dose. Next dose should be 2 hours after.
These only apply in patients without coagulopathies or additional anti-coagulation/anti-platelet drugs. Fondaparinux is a different beast, and current recommendation is to do neuroaxial techniques only in the setting of a clinical trial.
Page 11:
"Since 2003, there have been 5 cases of spontaneous spinal hematomas associated with LMWH. Four of these cases occurred with treatment dosing LMWH (exonaprin 1mg/kg twice daily).
It seems the rate of spinal hematoma is around 1:3,600 after daily dosing and spinal anesthetic. BID LMWH is clearly a no-go for neuraxial technique.
We rarely have surgeons order TID heparin. The guidelines indicate that BID heparin + compression devices = TID heparin for DVT prophylaxis.
We hold lumbar plexus single shots or catheters as same as neuraxial. The other regional blocks are done much more liberally.
These guidelines are likely overly conservative, and the quality of the evidence isn't always good. But, the consequences of spinal/epidural hematoma are devastating. Our acute pain service follows these guidelines closely. Hope this helps.
page 10 unfractionated heparin
3.2 no contraindication for neuraxial with 5000 units UFH bid SQ. Risk may be reduced by delaying heparin injection until after block is placed.
3.3 safety of TID dosing not established
page 13 LMWH
4.3 presence of blood during needle and catheter placement does not need to delay surgery
4.4.1 preop prophylaxis LMWH: needle placement should be 10-12 hours after last dose
4.4.2 treatment LMWH: should wait 24 hours after last dose
4.4.3 preop prophylaxis within 2 hours: no neuraxial technique recommended.
Postop LMWH
4.5.1 BID dosing: first dose should be administered no earlier than 24 hours, regardless of anesthetic technique. Catheters should be removed before initiation. LMWH should be delayed 2 hours after the catheter was removed.
4.5.2 Daily dosing: first dose should be administered 6-8 hours postop. Second dose should occur no earlier than 24 hours after the first dose. Catheters may be used but should be removed a minimum of 10-12 hours after the last dose. Next dose should be 2 hours after.
These only apply in patients without coagulopathies or additional anti-coagulation/anti-platelet drugs. Fondaparinux is a different beast, and current recommendation is to do neuroaxial techniques only in the setting of a clinical trial.
Page 11:
"Since 2003, there have been 5 cases of spontaneous spinal hematomas associated with LMWH. Four of these cases occurred with treatment dosing LMWH (exonaprin 1mg/kg twice daily).
It seems the rate of spinal hematoma is around 1:3,600 after daily dosing and spinal anesthetic. BID LMWH is clearly a no-go for neuraxial technique.
We rarely have surgeons order TID heparin. The guidelines indicate that BID heparin + compression devices = TID heparin for DVT prophylaxis.
We hold lumbar plexus single shots or catheters as same as neuraxial. The other regional blocks are done much more liberally.
These guidelines are likely overly conservative, and the quality of the evidence isn't always good. But, the consequences of spinal/epidural hematoma are devastating. Our acute pain service follows these guidelines closely. Hope this helps.
Thanks for the link. That's exactly what I was looking for.
This is an interesting topic because there's such a push for more chemical prophylaxis in the surgical community. A lot of people are giving pre-operative SQ heparin, usually on the morning of surgery. This would definitely be a problem if an epidural was planned. I'm wondering if it will lead to less frequent use of the epidural.
Also interesting is that 4/5 patients that got a hematoma on Lovenox were on therapeutic doses. I've never heard of someone using an epidural during systemic anticoagulation.
Proman, you mentioned BID LMWH being a no-go....you meant therapeutic doses, not prophylactic doses, right?
What are your thoughts (and practices) in regards to foley catheters? Do you recommend that they stay in while the epidural is in place?
Final question: Are you guys doing a lot of local-only epidurals, i.e. without narcotics, or do most of you still use a combo of local and narcotics in your epidurals?
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LMWH at any dose or frequency is a problem.
If the patient got a shot of LMWH (prophylactic dose) the morning of surgery I think that most anesthesiologists will not place an epidural.
If the LMWH is to be started post-op it looks like a minimum 12 hours wait period is required if an epidural has been placed.
These times are even more complicated if you are dealing with Fondaparinux since it is longer acting than LMWH.
Although the ASRA guidelines seem to try to answer some of these questions there are many issues that remain to be explained.
Even for SC prophylactic Heparin, although the ASRA guidelines state that it is not a contraindication, in the same sentence they say that delaying the needle placement 2 hours might reduce the risk!
If something is ok to do why sre we still talking about reducing risk?
As for Foley catheters I think every patient with a lumbar epidural should have one.
Low dose thoracic epidurals might be OK without a Foley.
As for using a narcotic with your local I don't see why you shouldn't.
If the patient got a shot of LMWH (prophylactic dose) the morning of surgery I think that most anesthesiologists will not place an epidural.
If the LMWH is to be started post-op it looks like a minimum 12 hours wait period is required if an epidural has been placed.
These times are even more complicated if you are dealing with Fondaparinux since it is longer acting than LMWH.
Although the ASRA guidelines seem to try to answer some of these questions there are many issues that remain to be explained.
Even for SC prophylactic Heparin, although the ASRA guidelines state that it is not a contraindication, in the same sentence they say that delaying the needle placement 2 hours might reduce the risk!
If something is ok to do why sre we still talking about reducing risk?
As for Foley catheters I think every patient with a lumbar epidural should have one.
Low dose thoracic epidurals might be OK without a Foley.
As for using a narcotic with your local I don't see why you shouldn't.
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The ASRA guidelines have already been discussed in previous posts. What I wanted to add was my experience: I've never had a problem with Heparin 5000 units SC bid.
I've seen some patients come in on much larger doses or even tid. On those taking tid, I've seen several significant elevations in PTT.
I'll give one anecdote: A couple of months ago there was one patient taking a larger dose of Heparin bid -- I forget the amount (I think 8500), but she was also a larger lady. She was for C/S. The shift before me had ordered coags. So I was forced to look at them and have found a PTT in the mid-40s. It had been about 4-5 since that was drawn when the decision for C/S was made. Since it was non-emergent, when they started to consider the C/S I had the OB team send off another set. There was no reason to suspect a coagulopathy other than this lady taking SC prophylactic Heparin, and she had no renal problems so I figured the value would be normalizing by now. The repeat came back about the same (42 seconds vs 45 seconds I think). My CRNA was ready to put an epidural in her, but I stopped him and we put her to sleep.
I love regional anesthesia (both neuraxial and blocks), but I have never regretted putting an ETT. When in doubt I tend to take the conservative route. Although this lady was a big and airway was a possible concern, I knew I had backup equipment available if needed. I would rather deal with potential aspiration than with an epidural/spinal hematoma.
I've seen some patients come in on much larger doses or even tid. On those taking tid, I've seen several significant elevations in PTT.
I'll give one anecdote: A couple of months ago there was one patient taking a larger dose of Heparin bid -- I forget the amount (I think 8500), but she was also a larger lady. She was for C/S. The shift before me had ordered coags. So I was forced to look at them and have found a PTT in the mid-40s. It had been about 4-5 since that was drawn when the decision for C/S was made. Since it was non-emergent, when they started to consider the C/S I had the OB team send off another set. There was no reason to suspect a coagulopathy other than this lady taking SC prophylactic Heparin, and she had no renal problems so I figured the value would be normalizing by now. The repeat came back about the same (42 seconds vs 45 seconds I think). My CRNA was ready to put an epidural in her, but I stopped him and we put her to sleep.
I love regional anesthesia (both neuraxial and blocks), but I have never regretted putting an ETT. When in doubt I tend to take the conservative route. Although this lady was a big and airway was a possible concern, I knew I had backup equipment available if needed. I would rather deal with potential aspiration than with an epidural/spinal hematoma.
Just askin' here, but care to guess what % of patients actually have urinary retention from a lumbar epidural? I seem to remember something around 11% or so.... then again, maybe I'm pullin that number outa my arse....
Not a lot, but on occasion and for medical reasons, we sometimes use local-only epidurals....
I can understand your perspective, and agree that there are a lot of unanswered questions.
Do you think that part of the problem is the difference in opinion between surgeons and anesthesiologists about the risk/benefit ratio of Lovenox? In anesthesia, the focus is usually on the patient in the immediate perioperative period. As surgeons, we are thinking about the more long-term patient outcomes....like DVT and PE.
If the patient gets an epidural hematoma, although a rare occurrence, it has a huge impact on the anesthesiologist. If the patient gets a DVT, although infinitely more common, it doesn't directly impact the anesthesiologist.
As for the dosing of LMWH and unfractionated heparin, I don't think there's a clear answer. In trauma ICU patients, we generally give Lovenox 30mg SQ BID. That is based on the fact that most of the trauma literature used that dose, and 40mg daily wasn't tested. I've read one article comparing the two, and BID seemed better. I bring it up because we often will ask for thoracic epidurals in these patients when they have a bunch of rib fractures.
Unfractionated heparin SQ q8 versus q12 is also unclear, but I found a few quick articles using trusty google that discuss it.
http://www.ncbi.nlm.nih.gov/pubmed/20177819
http://direct.bl.uk/bld/PlaceOrder.do?UIN=227049030&ETOC=RN&from=searchengine
I know there's some stuff in the medicine literature, but my medline search is coming up empty.
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I practice
EXACTLY
like this.👍
The ASA can post guidelines all they want.
I prefer to backstab my patients. Literally. In their back.
I'll defer backstabbing a patient by ignoring the REALITY THAT ANTICOAGULANTS AND NEURAXIAL ANESTHESIA DO NOT MIX
to someone else.
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There is. Wish I could recall it. Wishing MMD was still around since his a s s can recall studies quicker than I can recall what I ate for dinner last nite. I can tell you a cuppla years ago I received via snail mail a warning concerning LMWH and neuraxial anesthesia.
More importantly,
Thanks for posting here. Please come back.👍
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None of our acute pain attendings will do a catheter with BID LMWH, no matter the dose. It's really the timing of the peak and troughs of anticoagulation. With BID dosing, there's essentially no trough to pull the epidural.
I never understood the point of removing the opioid from the infusion. Sometimes the surgical service requests that if the patient is too sedated. We comply but it rarely helps.
The trauma patient with rib fractures is probably the hardest one to deal with. We've had issues getting everyone on board. I can't keep a trauma surgeon from ordering what we consider to be risky DVT prophylaxis. I can document the conversation and inform the patient. Hematomas are so rare that most people get away with it. I have done a spinal drain for TAA on a patient taking Ticlid. We felt the benefit of the drain far outweighed the risk of hematoma.
As for heparin, assuming the patient doesn't look like they were assaulted by Mike Tyson, BID or TID doesn't matter for us. We give a lot of preop SQ heparin. If the patient is getting an epidural, the preop nurses will not give it and we give it in the OR instead. That way there's at least an hour in between.
Hopkins. Why?
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They still use that drug? Wow. I haven't seen it since I was a med. student and it was going out of vogue.
As always its an individual (patient to patient) analysis of risk/benefit.
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I am not sure what percentage would actually have retention but I guess many factors would have to be considered here:
Male versus female (more in male),type of surgery(Abdominal and pelvic surgery versus peripheral surgery), length of surgery, use of anticholinergics, use of narcotics in the epidural...
Lets say post a 30 min c-section, all healthy females, 70KGs, with epidural running 1/8% bupiv with 2mcg/ml fent....the standard stuff... I do not think that urinary retention is more than 15% in this population, but I just do not know the numbers either. Seem to recall someone telling me around 11%...
We are practicing in the same geographical area...
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I'd say the incidence is so low because they all have foley catheters that are left in until the next morning.😀
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Had a patient today, 36 yo G1P0 at term, admitted this morning for induction of labor.
Healthy except for a PFO and a history of some TIAs after long plane rides. Because of the added hypercoagulability of pregnancy, she was on 16000 units heparin SQ bid. Otherwise no issues - except she carries the added risk factor of being a physician herself. 🙂
Last dose of heparin was 2230 last night. Platelets stable in the 240-260 range for the last month.
PTT at 0745 today was 50.9
PTT at 1145 today was 42.3
PTT at 1245 today was 36.7
Normal reference PTT for our lab is 23.9 - 33.1
16K bid is a big dose but even so I was surprised to see her PTT elevated 14+ hours after the last dose.
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PGG, I recently had a patient taking SC heparin due to hx DVT (I don't recall the dose or frequency) who presented for urgent C-section (pre-eclampsia, breech presentation, in labor). In any case, her last dose of heparin was >24 hrs ago and her PTT was still in the mid 40s. TEG showed significantly prolonged R time. We ended up inducing GA. My attending at the time indicated that he frequently observes prolonged PTT values in pts taking SC heparin despite the last dose being >12 hrs ago and, as such, he routinely checks coags on these pts.
