Todays Case

[Noyac]

71 yo Female for Redo THA after inability to keep the first hip in socket. History of Rheumatoid Arthritis on prednisone, HTN BP's 130-190/60-90 on metoprolol, PE on coumadin with INR 1.97. H/H 11.4/34. Anything else you need? Do you do the case or not? Surgeon is very good and has very little blood loss if you are wondering. And pt wants a spinal.

 

[Planktonmd]

No spinal unless INR is NORMAL.
If surgeon is willing to proceed then GA.

 

[Intrathecal]

How recent was the PE? Is there a guideline for discontinuing someone from coumadin prior to elective surgery with h/o PE?

From what I have seen at my university setting, hip revisions can be long with 1-2L of blood loss. Doesn't sound like a case we would move forward on, but then again I'm at teaching hospital. Spinal definitely sounds like a bad idea.

Let us know what you did and how it turned out

 

[The_Sensei]

71 yo Female for Redo THA after inability to keep the first hip in socket. History of Rheumatoid Arthritis on prednisone, HTN BP's 130-190/60-90 on metoprolol, PE on coumadin with INR 1.97. H/H 11.4/34. Anything else you need? Do you do the case or not? Surgeon is very good and has very little blood loss if you are wondering. And pt wants a spinal.

Tell pt. no spinal - GA - type and screen for 2 units since its a redo hip. Do these cases all the time here........no problems.

 

[militarymd]

no regional...ga for case.

 

[EtherMD]

No spinal unless INR is NORMAL.
If surgeon is willing to proceed then GA.

I have a perfomed about a thousand spinal anesthetics with a slightly abnormal INR. I use less than 1.5 as my cutoff. I am very RIGID with this number and have never had a complication with less than 1.5.

Even the best surgeon may lose more blood on a re-do hip with abnormal INR. Average blood loss for even the best surgeon is around 600cc's in my center. I would type and cross 2 unit PRBC's and do GA. At what point would I transfuse this patient? I would prefer cell saver and avoid the issue but without cell saver would use Hgb of around 8 as my number.

One last thing make sure you have a decent I.V. These types of patients may arrive with a tiny or poorly functioning I.V. After induction start a new I.V. if needed (can't hurt to have two I.V.'s in a re-do hip).

I have also had the fortune of losing two liters of more during one of these cases (re-do hip with abnormal INR) so be prepared!

 

[Planktonmd]

Abnormal INR = No neuroaxial block in my book.

 

[Noyac]

I did an epidural!


Just joking. So where I am headed with this is, what INR is acceptable for this type of surgery? Does it make a difference if the trend is dropping or rising? In other words, would you be more inclined to do the case or place a spinal in someone who's INR has just risen to 1.5 (also my cutoff for spinal/epidural) or in someone who's INR has just fallen to 1.5, assuming no other antiplatelet meds?

Yeah, I did the case. GA and we lost very little blood. Hct went from 34 to 32, no cell saver. Granted this was b/4 redistribution but as of this morning she has not needed to be transfused.

 

[EtherMD]

I did an epidural!


Just joking. So where I am headed with this is, what INR is acceptable for this type of surgery? Does it make a difference if the trend is dropping or rising? In other words, would you be more inclined to do the case or place a spinal in someone who's INR has just risen to 1.5 (also my cutoff for spinal/epidural) or in someone who's INR has just fallen to 1.5, assuming no other antiplatelet meds?

Yeah, I did the case. GA and we lost very little blood. Hct went from 34 to 32, no cell saver. Granted this was b/4 redistribution but as of this morning she has not needed to be transfused.

All I can do is tell you about 12,000 or so cases that my Group has performed under spinal with an abnormal INR. Yes, you read it right 12,000 spinals with an abnormal INR less than or equal to 1.5 and ZERO complications. Admittedly, we are experienced MDA's but still this is a lot of data. Please notice I am referencing spinals and not Epidurals as I believe the risk from Epidural placement is greater with an abnormal INR.

If the INR is rising I would want a recent (last few hours ) INR and current platelet count. Any use of platelet inhibitors would factor into my decision as well. Also, the use of a cutting vs. non-cutting needle and the anticipated difficulty of the stick (this is guess) would be factors as well. Finally, the ASA status of the patient and type of case.