VWD and neuraxial

[rick roller pump]

Interested to see what people would do in this situation.
Say you have a lady on OB with type 1 VWD. No testing in the system. Any VWD specific testing would be a send out lab so takes a couple days. Can get labs like coags or TEG but not sure how helpful that would be. Patient wants an epidural.
Options I see are:
1. Just do it. In this paper neuraxial was performed without pretreatment in most type 1 patients without issue (Anesthetic Management of Von Willebrand Disease in... : Anesthesia & Analgesia). Not sure if this is defensible though.
2. Give DDAVP then do it
3. Give VWF concentrate then do it
4. Refuse

I would probably go with option 2, but wonder if this is reckless without formal testing. Obviously it is an elective procedure. But I hate to refuse to do things without good evidence.

I am assuming for Type 2 and 3 VWD, no one is doing neuraxial without first giving factor concentrate +/- talking with Hematologist?

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[abolt18]

Interested to see what people would do in this situation.
Say you have a lady on OB with type 1 VWD. No testing in the system. Any VWD specific testing would be a send out lab so takes a couple days. Can get labs like coags or TEG but not sure how helpful that would be. Patient wants an epidural.
Options I see are:
1. Just do it. In this paper neuraxial was performed without pretreatment in most type 1 patients without issue (Anesthetic Management of Von Willebrand Disease in... : Anesthesia & Analgesia). Not sure if this is defensible though.
2. Give DDAVP then do it
3. Give VWF concentrate then do it
4. Refuse

I would probably go with option 2, but wonder if this is reckless without formal testing. Obviously it is an elective procedure. But I hate to refuse to do things without good evidence.

I am assuming for Type 2 and 3 VWD, no one is doing neuraxial without first giving factor concentrate +/- talking with Hematologist?

Where I trained this patient 100% would have had a full workup with treatment recommendations from hematology otherwise no neuraxial. It's not like it's a surprise. OB should have sent this patient to hematology, or at least anesthesia (who would have consulted hematology) SOMETIME in the preceding 9 months.

I would do as I was trained.

 

[2019medstudent]

In my group, none of us would do anything without a heme consult.

 

[BlueRug]

Data would support TEG/ROTEM use here; however since it's OB, heme consult for CYA.

A prospective diagnostic accuracy study evaluating rotational thromboelastometry and thromboelastography in 100 patients with von Willebrand disease - PubMed

Thromboelastography R and CI accurately discriminated VWD patients from healthy controls, partly through the detection of low FVIII levels. The test's performance may be improved through adjustment of the test thresholds to a local reference population. Both intrinsic pathway-activated (INTEM)...

pubmed.ncbi.nlm.nih.gov

 

[GassYous]

When the risk is catastrophic bleeding and paralysis or worse, I'm not sure that doing an elective procedure is warranted

 

[Maz777]

Heme consult at the minimum. This isn't the time to be a cowboy.

 

[rick roller pump]

Thanks everyone

 

[UscGhost]

Ask the OB why in the world they didn't get a heme consult in early admission

Get a heme consult

More interesting question would be if it's a emergency csxn. Is spinal still safer than GA?

 

[abolt18]

Ask the OB why in the world they didn't get a heme consult in early admission

Get a heme consult

More interesting question would be if it's a emergency csxn. Is spinal still safer than GA?

Same story. No neuraxial period without heme-onc weighing in, unless there were unbelievable extenuating circumstances that made intubation exceptionally undesirable (massive, friable, head/neck cancer obstructing airway. Severe trismus with 0.5cm mouth opening, etc ). But there you're weighing the risk of epidural bleed vs catastrophic failed airway and all its sequelae, which may be highly likely in these scenarios.

 

[coffeebythelake]

Ask the OB why in the world they didn't get a heme consult in early admission

Get a heme consult

More interesting question would be if it's a emergency csxn. Is spinal still safer than GA?

Newer data show that GA is only a marginally higher risk vs neuraxial for vast majority of parturients