Unusual Epidural Quandry

[Pilot Doc]

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Disoriented trauma patient has bitten through his epidural tubing between the pump and the hub of the catheter. Received lovenox 30mg three hours prior. Take it out now or wait?

 

[pushthesux]

Between pump and hub...just replace the bag and tubing, right?

Or just pull it out and it gives you an excuse to snow him with narcs.

 

[LongSnow]

I would stop the infusion, hold lovenox, wait 24 hours after last dose, pull the cath, then wait 2 hours, then restart lovenox. Narcs for pain control. this is assuming the higher dose lovenox, if lower dose lovenox, can wait 12 hours to pull cath after loast dose. I would also trim the epidural cath as short as possible, and recap it. Also check INR, platelets prior to removal

Good place to look is ASRA consensus statement:

http://www.asra.com/consensus-statements/2.html

 

[BLADEMDA]

How long should one wait following a dose of enoxaparin for thromboprophylaxis to remove an epidural catheter?

[SIZE=+1]R[/SIZE]emoval of an epidural catheter may potentially dislodge clot within the epidural space. In 15 of 32 cases of spinal hematomas reported by Vandermeulen where an epidural catheter was used, spinal bleeding occured immediately after the removal of the epidural catheter[SIZE=-2]10[/SIZE]. A period of 10-12 hours after the last dose of enoxaparin is recommended before removing a catheter[SIZE=-2]2, 7, 10[/SIZE].

Unfortunately there is little data regarding the continued use of low molecular weight heparin while an epidural catheter is in place. Although it appears to be safe, an increased risk may be associated with catheter movement in the epidural space during flexion or extension of the spine which may traumatize veins or preexisting clot.

REFERENCES

2. Horlocker-TT, Heit-JA. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for reginoal anesthestic management [review]. Anesth Analg 1997;85:874-85.

7. Hynson-J-M, Katz-J-A, Ulrich Bueff-H. Epidural hematoma associated with enoxaparin [case report]. Anesth Analg 1996; 82:1072-5.

10. Vandermeulen-EP, Aken HV, Vermylen-J. Anticoagulants and Spinal-Epidural Anesthesia [Review]. Anesth Analg 1994;79:1165-77.

 

[BLADEMDA]

Specific Recommendations from The American Society of Regional Anesthesia and Pain Medicine Consensus Conference on Neuraxial Anesthesia and Anticoagulation include:

• <LI class=MsoNormal style="TEXT-ALIGN: justify">Preoperative Warfarin
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">Chronic warfarin therapy should be stopped 4-5 days prior to neuraxial anesthesia.
    • Normal range INR values are associated with normal hemostasis when discontinuing chronic warfarin therapy.
  • INR should be measured prior to initiation of neuraxial block
  <LI class=MsoNormal style="TEXT-ALIGN: justify">Postoperative Warfarin
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">The analgesic solution used for neuraxial block should be tailored to minimize the degree of sensory and motor block. <LI class=MsoNormal style="TEXT-ALIGN: justify">INRs < 1.5 are associated with normal hemostasis on initial of warfarin
    • INR should be < 1.5 when the epidural catheter is pulled
  • Warfarin should be withheld or reduced in patients with indwelling neuraxial catheters when the INR is > 3.
  <LI class=MsoNormal style="TEXT-ALIGN: justify">Preoperative LMWH
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">Needle placement should be no sooner than
    • 24 hours after therapeutic doses of Lovenox (DVT/PE treatment)
    • 10-12 hours after prophylaxis with single daily dose of LMWH
  <LI class=MsoNormal style="TEXT-ALIGN: justify">Postoperative LMWH
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">Lovenox should be given no sooner than 2 hours after catheter removal and should be delayed 24 hours postoperatively if blood is present during needle or catheter placement. <LI class=MsoNormal style="TEXT-ALIGN: justify">LMWH (twice daily dosing prophylaxis regimens,)
    • <LI class=MsoNormal style="TEXT-ALIGN: justify">Initiated postoperatively should start no earlier than 24 hours postoperatively
    • If continuous technique used, remove catheter at least 2 hours before 1st dose of LMWH
    <LI class=MsoNormal style="TEXT-ALIGN: justify">LMWH (Single daily dosing prophylaxis regimens)
    • <LI class=MsoNormal style="TEXT-ALIGN: justify">First dose 6-8 hours postoperatively <LI class=MsoNormal style="TEXT-ALIGN: justify">Second dose of LWMH should be given no sooner than 24 hours after the first dose.
    • Catheter should be removed a minimum of 10-12 hours after the last dose of LMWH
    • Lovenox should be given no sooner than 2 hours after catheter removal and should be delayed 24 hours postoperatively if blood is present during needle or catheter placement.
  <LI class=MsoNormal style="TEXT-ALIGN: justify">Antiplatelet Medications
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">Plavix (Clopidogrel) should be discontinued 7 days prior to neuraxial blockage.
  • Ticlid (Ticlopidine) should be discontinued 10-14 days prior neuraxial blockage.
  <LI class=MsoNormal style="TEXT-ALIGN: justify">2b/3a Inhibitors:
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">2b/3a inhibitors (Integrilin, Aggrastat) should be discontinued 8 hours prior to neuraxial blockage
  • Reopro (abciximab) should be discontinued 24-48 hours prior to neuraxial blockage.
  <LI class=MsoNormal style="TEXT-ALIGN: justify">Heparin
  • <LI class=MsoNormal style="TEXT-ALIGN: justify">Heparin intravenous
    • <LI class=MsoNormal style="TEXT-ALIGN: justify">Start heparin > 1 hour after neuraxial technique
    • Remove catheter 2-4 hours after heparin infusion stopped, assess coagulation status prior to neuraxial catheter removal
    <LI class=MsoNormal style="TEXT-ALIGN: justify">Combining neuraxial techniques with intraoperative anticoagulation with heparin during vascular surgery seems acceptable with the following cautions:
    • <LI class=MsoNormal style="TEXT-ALIGN: justify">Avoid this technique in patients with other coagulopathies <LI class=MsoNormal style="TEXT-ALIGN: justify">Heparin administration should be delayed for 1 hour after needle placement <LI class=MsoNormal style="TEXT-ALIGN: justify">Indwelling neuraxial catheters should be removed 2-4 hours after the last heparin dose and the patients coagulation status is evaluated and re-heparinization should occur 1 hour after catheter removal
    • Monitor the patient postoperatively to provide early detection of motor block and consider use of minimal concentration of local anesthetics to enhance the early detection of a spinal hematoma
    <LI class=MsoNormal style="TEXT-ALIGN: justify">Cardiopulmonary bypass
    • <LI class=MsoNormal style="TEXT-ALIGN: justify">Full dose heparin should be discontinued 2-4 hours prior to neuraxial catheter remove. <LI class=MsoNormal style="TEXT-ALIGN: justify">Neuraxial blocks should be avoided in patients with known coagulopathy from any cause <LI class=MsoNormal style="TEXT-ALIGN: justify">Surgery should be delayed 24 hours in the event of a traumatic tap <LI class=MsoNormal style="TEXT-ALIGN: justify">Time from instrumentation to systemic heparinization should exceed 60 minutes
    • Epidural catheters should be removed when normal coagulation is restored
  • Subcutaneously Heparin
    • Low dose heparin 5000 units subcutaneously q12 hours may be used. If therapy last longer than 4 days, platelets should be monitored prior to neuraxial block and catheter removal.
• Systemic Thrombolytics
  • Patients receiving fibrinolytic and thrombolytic drugs should be cautioned against receiving spinal or epidural anesthetics except in highly unusual circumstances. Data are not available to clearly outline the length of time neuraxial puncture should be avoided after discontinuation of these drugs.

 

[BLADEMDA]

peripheral nerve block in combat casualties receiving low-molecular weight heparin.

REGIONAL ANAESTHESIA
BJA: British Journal of Anaesthesia. 97(6):874-877, December 2006.
Buckenmaier, C. C. III *; Shields, C. H.; Auton, A. A.; Evans, S. L.; Croll, S. M.; Bleckner, L. L.; Brown, D. S.; Stojadinovic, A.

Abstract:
Background: Continuous peripheral nerve block (CPNB) is an important therapeutic tool in the anaesthetic and analgesic management of combat casualties at Walter Reed Army Medical Center (WRAMC). We describe our experience using CPNB techniques in combat trauma patients treated with low-molecular weight heparin (LMWH). Guidelines used at our institution for managing CPNB catheters in patients being treated with LMWH are introduced.
Methods: From March 2003 to April 2005, 187 combat casualties treated by the WRAMC regional anaesthesia/acute pain section using CPNB were evaluated retrospectively by electronic chart review. Patient characteristic data, CPNB type, duration of CPNB, indication for LMWH [enoxaparin sodium injection (Lovenox(R)-Sanofi Aventis, Bridgewater, NJ, USA)], enoxaparin dose (mg) before and after catheter insertion and removal, time from CPNB placement and removal to enoxaparin dose, and complications were recorded.
Results: Median enoxaparin dose and time given before catheter insertion were 30 mg and 21 h, respectively. Median enoxaparin dose was also 30 mg given a median of 12 h after peripheral nerve catheter placement. Catheters remained in situ for a median of 8 days (range 1-33 days). Catheter specific complications were infrequent and identified in 7 (3.7%) patients (two catheter malfunction-kinking, catheter tip dislodgement in situ, two superficial catheter site infections and two catheter dislocations). There were no catheter-related bleeding complications evident in this study.
Conclusions: Information regarding the safety of CPNB in patients treated with LMWH for perioperative venous thromboembolism prevention is scarce. Our initial experience with CPNB and concurrent LMWH has not been complicated by catheter-related bleeding. (C) The Board of Management and Trustees of the British Journal of Anesthesia 2006. Published by Oxford University Press. All rights reserved.

 

[Fastrach]

Between pump and hub...just replace the bag and tubing, right?

Or just pull it out and it gives you an excuse to snow him with narcs.

Please tell me you were joking about this... 😱

 

[Frank Rizzo]

Disoriented trauma patient has bitten through his epidural tubing between the pump and the hub of the catheter. Received lovenox 30mg three hours prior. Take it out now or wait?

once a day or twice a day 30mg?

I'd recap it so its not open to air, stop the infusion and pull it after 12 hours. Probably aren't any studies out there of the rate of infection of a bitten catheter that is turned off, but I would imagine the rate is slim to none. Rate of hematoma... small, but slightly higher.

 

[Jeff05]

30mg is a prophylactic and not treatment dose.
blade is right, wait for 12 hours and pull catheter.

 

[DreamLover]

30mg is a prophylactic and not treatment dose.
blade is right, wait for 12 hours and pull catheter.

Yep-from what I have noticed, the prophylactic dose of Lovenox is either 40mg QD or 30mg BID, but either way, it's wait 12 hrs and pull it, then wait at least 2 hrs before restarting. Wait 24 hrs if the pt is receiving a therapeutic dose of Lovenox before pulling! Those ASRA guidelines are definitely helpul to memorize!!!

 

[Pilot Doc]

The guidelines for typical epidural pulls are easy enough to find. The issue here is balancing infectious vs. bleeding risk. Am I the only one who finds a catheter contaminated with oral flora worrisome?

 

[SleepIsGood]

The guidelines for typical epidural pulls are easy enough to find. The issue here is balancing infectious vs. bleeding risk. Am I the only one who finds a catheter contaminated with oral flora worrisome?

if she bit it off.....I would likely try to 'wash' the end off with a alcohol pad. then just make a knot and 'tie' it off since i dont think you can 'cap' it any longer.

then keep it in there for 24 hrs and then pull it out.

 

[aredoubleyou]

The guidelines for typical epidural pulls are easy enough to find. The issue here is balancing infectious vs. bleeding risk. Am I the only one who finds a catheter contaminated with oral flora worrisome?

Clean the catheter, trim it, put a new little yellow thingy at the end, tape it to his back, pull it 12 hours later. If he bleeds you caused it. If he gets an abcess, he caused it.

 

[Bertelman]

I'm not so worried about infection. He bit through the tubing, which presumably stopped the actual infusion of medication. I would guess at that point, the likely migration (if any) of fluid in the catheter is OUT of his body. Microbial motion is somewhat random, and would likely take quite some time to reach his epidural spaceSince it was the tubing, the microbes would have to navigate a filter before making it to the actual catheter.

If this had happened in the middle of the night, and proceeded unnoticed for hours, I would be more concerned. If it were an intrathecal catheter, I would be more concerned. Either way, as mentioned there are guidelines for pulling catheters with anticoagulation. I would have to find a very compelling reason to go against those guidelines, and this doesn't appear to be one.

I say remove tubing, filter and catheter cap. Replace cap. Tape to his back so he cannot access. Remove in 9 hrs.

 

[Jeff05]

if she bit it off.....I would likely try to 'wash' the end off with a alcohol pad. then just make a knot and 'tie' it off since i dont think you can 'cap' it any longer.

then keep it in there for 24 hrs and then pull it out.

you can pull it after 12 hours.

 

[periopdoc]

Though the topic has been beaten to death now, I thought I would add that I would clean it, cap it or tie it, and pull it 12 hours after the last lovenox.

I would also treat him prophylactically for oral flora until the catheter is out.

- pod

 

[Frank Rizzo]

Clean the catheter, trim it, put a new little yellow thingy at the end...

Exactly. This is what I meant when I said to 'cap it', but I guess I should have been more clear. You have plenty of catheter hanging out of the the nut's back. Clean it, cut half of it off, recap it, and pull 12 hours later.