Spinal and intraop heparin use

[Chloroform4Life]

Pt present for femoral endarterectomy and has bad copd. Normal preop coags and not on blood thinner. spinal. Give 5000 unit heparin intraop.

Problem?

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[vector2]

Pt present for femoral endarterectomy and has bad copd. Normal preop coags and not on blood thinner. spinal. Give 5000 unit heparin intraop.

Problem?

Only if you didn't wait an hour from needle to heparinization time. Would also be a little wary heparinizing if it was traumatic at all.

"
http://www.nysora.com/mobile/region...-of-ra/3300-ra-in-anticoagulated-patient.html


Intravenous Heparin

Heparin is a complex polysaccharide that exerts its anti- coagulant effect by binding to antithrombin III. The conformational change in antithrombin accelerates its ability to inactivate thrombin, factor Xa, and factor IXa. The anticoagulant effect of subcutaneous heparin takes 1 to 2 hours, but the effect of intravenous heparin is immediate. Heparin has a half-life of 1.5 to 2 hours. The activated partial thromboplastin time (aPTT) is used to monitor the effect of heparin; therapeutic anticoagulation is achieved with a prolongation of the aPTT to >1.5 times the baseline value.

There were no spinal hematomas in >4000 patients who underwent lower extremity vascular surgery under contin- uous spinal or epidural anesthesia.(22) In this study, patients with preexisting coagulation disorders were excluded, heparinization occurred at least 60 minutes after cath- eter placement, the level of anticoagulation was carefully monitored, and the indwelling catheters were removed at a time when heparin activity was low. Ruff and Dougherty (23) noted the occurrence of spinal hematomas in patients who underwent lumbar puncture with subsequent hepa- rinization. The presence of blood during the procedure, concomitant aspirin therapy, and heparinization within 1 hour were identified as risk factors for the development of a spinal hematoma.

When intraoperative anticoagulation is planned, neuraxial technique should be avoided in patients with coexisting coagulopathies. The following considerations are in order:

1. There should be at least a 1-hour delay between needle placement and heparin administration.

2. The catheter should be removed 1 hour before subsequent heparin administration and 2 to 4 hours after the last heparin dose.(4)

3. The partial thromboplastin time or activated clotting time should be monitored to avoid excessive heparin effect.
"

 

[caligas]

Only if you didn't wait an hour from needle to heparinization time. Would also be a little wary heparinizing if it was traumatic at all.

"
http://www.nysora.com/mobile/region...-of-ra/3300-ra-in-anticoagulated-patient.html


Intravenous Heparin

Heparin is a complex polysaccharide that exerts its anti- coagulant effect by binding to antithrombin III. The conformational change in antithrombin accelerates its ability to inactivate thrombin, factor Xa, and factor IXa. The anticoagulant effect of subcutaneous heparin takes 1 to 2 hours, but the effect of intravenous heparin is immediate. Heparin has a half-life of 1.5 to 2 hours. The activated partial thromboplastin time (aPTT) is used to monitor the effect of heparin; therapeutic anticoagulation is achieved with a prolongation of the aPTT to >1.5 times the baseline value.

There were no spinal hematomas in >4000 patients who underwent lower extremity vascular surgery under contin- uous spinal or epidural anesthesia.(22) In this study, patients with preexisting coagulation disorders were excluded, heparinization occurred at least 60 minutes after cath- eter placement, the level of anticoagulation was carefully monitored, and the indwelling catheters were removed at a time when heparin activity was low. Ruff and Dougherty (23) noted the occurrence of spinal hematomas in patients who underwent lumbar puncture with subsequent hepa- rinization. The presence of blood during the procedure, concomitant aspirin therapy, and heparinization within 1 hour were identified as risk factors for the development of a spinal hematoma.

When intraoperative anticoagulation is planned, neuraxial technique should be avoided in patients with coexisting coagulopathies. The following considerations are in order:

1. There should be at least a 1-hour delay between needle placement and heparin administration.

2. The catheter should be removed 1 hour before subsequent heparin administration and 2 to 4 hours after the last heparin dose.(4)

3. The partial thromboplastin time or activated clotting time should be monitored to avoid excessive heparin effect.
"

One hour may not be practical with many private practice surgeons (assuming no heme.)

 

[Chloroform4Life]

One hour is not practical unless surgeon is willing to wait around. Closer to 30 minutes is likely.

I know what the Asra guideline says, but I want y'all opinion on this.

My issue with the asra guideline is that it treats epidural, spinal, and even peripheral nerve blocks the same. And it's based mostly on expert opinions and not real evidence. I would argue that the risk of epidural hematoma after a spinal is negligible in someone with normal coagulation, even if they get 5000 units of heparin 30 minutes later.

Guidelines are guidelines, patients should be treated differently based on their situation. How often have we ignore asra guideline when it comes to peripheral nerve blocks?

 

[caligas]

One hour is not practical unless surgeon is willing to wait around. Closer to 30 minutes is likely.

I know what the Asra guideline says, but I want y'all opinion on this.

My issue with the asra guideline is that it treats epidural, spinal, and even peripheral nerve blocks the same. And it's based mostly on expert opinions and not real evidence. I would argue that the risk of epidural hematoma after a spinal is negligible in someone with normal coagulation, even if they get 5000 units of heparin 30 minutes later.

Guidelines are guidelines, patients should be treated differently based on their situation. How often have we ignore asra guideline when it comes to peripheral nerve blocks?

Yes, if it's an epidural for AAA or something than you want the full hour, but that's usually not an issue. Spinal, no heme for peripheral vascular rarely gets the full hour.

 

[Pooh & Annie]

Guidelines are guidelines, patients should be treated differently based on their situation. How often have we ignore asra guideline when it comes to peripheral nerve blocks?

I know what you mean, but in my mind there's a BIG difference between taking a chance with a PNB vs a neuraxial procedure.

 

[drmwvr]

Pt present for femoral endarterectomy and has bad copd. Normal preop coags and not on blood thinner. spinal. Give 5000 unit heparin intraop.

Problem?

Wouldn't/haven't think/thought twice about it. A clean single pass with a 24 or 25 GA needle? Even if the heparin were 30 minutes later, which would be pretty common.

 

[BLADEMDA]

30 minutes for SAB

1 hour for Epidural

For atraumatic Neuraxial blocks and low dose heparin if given IV prior to 60 minutes post block (less than 10,000 units).

 

[BLADEMDA]

A review of the literature noted no spinal haematomas in more than 9000 patients who received subcutaneous heparin in combination with spinal or epidural anaesthesia.24 There are only four cases of spinal haematoma associated with neuraxial block in the presence of low-dose heparin, three of which involved a continuous epidural anaesthetic technique.34

 

[BLADEMDA]

Ruff and Dougherty compared the incidence of spinal hematoma in patients undergoing lumbar puncture with or without concomitant heparin therapy (5). Patients with a history of preexisting coagulopathy were excluded. They reported that 2% of the patients receiving intravenous heparin developed a spinal hematoma after diagnostic lumbar puncture with a 20-gauge needle, whereas none of the patients in the nonheparin group developed a hematoma. Complications in both groups were exacerbated by traumatic needle insertion. Additionally, the anticoagulated patient group experienced a higher incidence of complications if anticoagulation was begun within 1 hour of neuraxial needle insertion, and this was exacerbated if the patients also received aspirin. Tryba found that the incidence of spinal hematoma in patients who did not receive intravenous heparin ranged from 1:220,000 (epidural anesthesia) to 1:320,000 (spinal anesthesia) (1). However, the incidence of hematoma formation was 10 times higher in the presence of a traumatic tap and in patients already receiving heparin or aspirin (1:70,000 to 1:150,000).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1276639/

 

[BLADEMDA]

http://stroke.ahajournals.org/content/12/6/879.full.pdf

Here is the article from 1981. It is the one we based the "one hour rule" for giving heparin after a spinal block.

 

[BLADEMDA]

Intravenous and Subcutaneous Standard Heparin The safety of neuraxial techniques in combination with intraoperative heparinization is well documented, providing no other coagulopathy is present. In a study involving over 4000 patients, Rao and El-Etr (10) demonstrated the safety of indwelling spinal and epidural catheters during systemic heparinization during vascular surgery. However, the heparin was administered at least 60 minutes after catheter placement, level of anticoagulation was closely monitored, and the indwelling catheters were removed at a time when circulating heparin levels were relatively low. A subsequent study in the neurologic literature by Ruff and Dougherty (11) reported spinal hematomas in 7 of 342 patients (2%) who underwent a diagnostic lumbar puncture and subsequent heparinization. Traumatic needle placement, initiation of anticoagulation within one hour of lumbar puncture and concomitant aspirin therapy were identified as risk factors in the development of spinal hematoma in anticoagulated patients. Subsequent studies using similar methodology have verified the safety of this practice, provided the monitoring of anticoagulant effect and the time intervals between heparinization and catheter placement/removal are maintained. Low-dose subcutaneous standard (unfractionated) heparin is administered for thromboprophylaxis in patients undergoing major thoracoabdominal surgery and in patients at increased risk of hemorrhage with oral anticoagulant or low molecular weight heparin (LMWH) therapy. There are nine published series totaling over 9,000 patients who have received this therapy without complications(12), as well as extensive experience in both Europe and United States without a significant frequency of complications. There are only five case reports of neuraxial hematomas, four epidural (2,13) and one subarachnoid,(14) during neuraxial block with the use of subcutaneous heparin. 3 The largest study of thrice daily unfractionated heparin involved 768 epidural catheter placements. Sixteen patients from this group had a positive match for hemorrhage codes on their discharge records, with none of the episodes being identified within a major hemorrhage category. Laboratory value analysis failed to reveal changes in the aPTT values of significance (4). The safety of neuraxial blockade in patients receiving doses greater than 10,000 U of UFH daily or more than twice-daily dosing of UFH has not been established. Although the use of thrice-daily UFH may lead to an increased risk of surgical-related bleeding, it is unclear whether there is an increased risk of spinal hematoma. If thrice-daily unfractionated heparin is administered, techniques to facilitate detection of new/progressive neurodeficits (eg, enhanced neurologic monitoring occur and neuraxial solutions to minimize sensory and motor block) should be applied.

http://www2.kenes.com/asraspring201..._Neuraxial Anesthesia and Anticoagulation.pdf

 

[BLADEMDA]

Anaesthesia. 1991 Aug;46(8):623-7.
Lumbar regional anaesthesia and prophylactic anticoagulant therapy. Is the combination safe?
Wille-Jørgensen P1, Jørgensen LN, Rasmussen LS.
Author information

• 1Department of Surgical Gastroenterology F, Bispebjerg Hospital, Copenhagen.

Abstract
A survey has been carried out in all Danish anaesthetic departments (n = 80) regarding the attitude towards the use of epidural/spinal lumbar analgesia in patients who were receiving prophylactic anticoagulant therapy for the prevention of thromboembolism. About 60% of the departments used the techniques in patients receiving low-dose heparin and no side effects had been experienced. Spinal and epidural anaesthesia were in general regarded as being contraindicated in patients fully anticoagulated with vitamin K antagonists. In the world literature, the attitude towards the combination is conflicting. No randomised trial has been performed and complications are almost entirely confined to patients fully anticoagulated with vitamin K antagonists. Only one case of an epidural haematoma has been recorded when subcutaneous low-dose heparin was used as thromboprophylaxis.

 

[nimbus]

We almost always put lumbar drains in before tevar. Granted more than one hour elapses before the patients are heparinized. But we haven't encountered a spinal hematoma yet. The 1 hour rule seems completely arbitrary and unscientific. Why not 45 min or 65 min?

 

[Chloroform4Life]

We almost always put lumbar drains in before tevar. Granted more than one hour elapses before the patients are heparinized. But we haven't encountered a spinal hematoma yet. The 1 hour rule seems completely arbitrary and unscientific. Why not 45 min or 65 min?

Exactly! I would argue that big ass touhy, an indwelling catheter plus big heparin dose 1 hour later is much riskier than a small spinal needle and a smaller heparin dose 30 minutes later. Yet the asra guideline would support the former practice and not the later.

 

[BLADEMDA]

Exactly! I would argue that big ass touhy, an indwelling catheter plus big heparin dose 1 hour later is much riskier than a small spinal needle and a smaller heparin dose 30 minutes later. Yet the asra guideline would support the former practice and not the later.

25G or 22G non cutting needle should be much safer and less traumatic than a 20G Q or 17G Epidural needle. But, the recommendations by ASRA still stand.

 

[nimbus]

25G or 22G non cutting needle should be much safer and less traumatic than a 20G Q or 17G Epidural needle. But, the recommendations by ASRA still stand.

Or a 14g tuohy

 

[Planktonmd]

Pt present for femoral endarterectomy and has bad copd. Normal preop coags and not on blood thinner. spinal. Give 5000 unit heparin intraop.

Problem?

No problem

 

[dhb]

For the sake of discussion since everyone is saying "no heme" what would you do if you get blood through the needle? The damage is already done so you must cancel the case right? (probably no one has done this..)

 

[pgg]

Wouldn't/haven't think/thought twice about it. A clean single pass with a 24 or 25 GA needle? Even if the heparin were 30 minutes later, which would be pretty common.

I love to hear people say things like this, that they'd be comfortable doing a procedure if it's "just one pass". But how do you know it will be? What do you do if your single pass fails? Even easy-looking patients and procedures surprise us sometimes.

So what do you do? One more clean single pass? Then one more? Abort, do something else?

 

[BLADEMDA]

For the sake of discussion since everyone is saying "no heme" what would you do if you get blood through the needle? The damage is already done so you must cancel the case right? (probably no one has done this..)

Heme means you need to wait one hour until you give the heparin. While the Surgeon will bitch and complain I'd make him wait the full hour.

 

[drmwvr]

I love to hear people say things like this, that they'd be comfortable doing a procedure if it's "just one pass". But how do you know it will be? What do you do if your single pass fails? Even easy-looking patients and procedures surprise us sometimes.

So what do you do? One more clean single pass? Then one more? Abort, do something else?

Ok, 12 passes.... then I'd put 'em to sleep. Clearer?

 

[caligas]

For the sake of discussion since everyone is saying "no heme" what would you do if you get blood through the needle? The damage is already done so you must cancel the case right? (probably no one has done this..)

Like Blade said, heme: wait one hour before heparin. No heme: just do the case OR dont choose spinal as your plan for peripheral vascular cases.

 

[drmwvr]

Like Blade said, heme: wait one hour before heparin. No heme: just do the case OR dont choose spinal as your plan for peripheral vascular cases.

Again...arbitrary. A clean pass is no indicator at all of an atraumatic spinal or epidural. Tempest in a teapot.