Your Group's Policy on Epidural Removal and Heparin infusion

[Jay K]

Recently placed an epidural in a patient undergoing lower extremity vascular bypass surgery per surgeon request (epidural + mac for the anesthetic in a patient with significant list of co-morbidities). Throughout the case, Heparin IVP was given as is standard, and then surgeon requested starting a heparin infusion after the case was completed. My group, interestingly enough, only has a policy regarding intermittent subcut heparin injections and timing the removal of epidural catheters - these are on standardized written orders made up by the group for nursing staff on the floor to follow. When I inquired of a few partners, the group's policy re: heparin infusion and epidural catheter removal, they were stymied. Reviewing ASRA's consensus statement, it appears that pt's undergoing vascular surgery and receiving anticoagulation via heparin are recommended to have indwelling catheters removed 2-4 hrs after the last heparin dose and the pt's coagulation status evaluated. It's hard to clarify whether the consensus statement refers to IVP doses or a constant infusion.

Do your groups have a policy regarding heparin infusion post-op and the removal of indwelling epidural catheters?

In this patient, the group decided to pull the catheter 2 hrs after the last intra-op dose (at end of case) and not to start the heparin infusion for a period of 2 hours after the catheter was removed.

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[Jeff05]

Recently placed an epidural in a patient undergoing lower extremity vascular bypass surgery per surgeon request (epidural + mac for the anesthetic in a patient with significant list of co-morbidities). Throughout the case, Heparin IVP was given as is standard, and then surgeon requested starting a heparin infusion after the case was completed. My group, interestingly enough, only has a policy regarding intermittent subcut heparin injections and timing the removal of epidural catheters - these are on standardized written orders made up by the group for nursing staff on the floor to follow. When I inquired of a few partners, the group's policy re: heparin infusion and epidural catheter removal, they were stymied. Reviewing ASRA's consensus statement, it appears that pt's undergoing vascular surgery and receiving anticoagulation via heparin are recommended to have indwelling catheters removed 2-4 hrs after the last heparin dose and the pt's coagulation status evaluated. It's hard to clarify whether the consensus statement refers to IVP doses or a constant infusion.

Do your groups have a policy regarding heparin infusion post-op and the removal of indwelling epidural catheters?

In this patient, the group decided to pull the catheter 2 hrs after the last intra-op dose (at end of case) and not to start the heparin infusion for a period of 2 hours after the catheter was removed.

ASRA recommends 2-4 hour wait (germany/spain recommend 4) to remove catheter after stopping IV heparin and waiting 1 hour to restart.


this brings up another interesting topic though - GA vs regional for vascular.
any good new data aside from this:
http://www.ncbi.nlm.nih.gov/pubmed/8572352

 

[Jay K]

To throw another option into the mix - I'd given some thought to placing an intrathecal catheter for the case instead. Opinions re: epidural vs intrathecal catheter for lower extremity vascular cases in significantly co-morbid patients?

 

[Bertelman]

I think the last time I did one of these I waited 4 hrs to pull, 2 to resume.

 

[IN2B8R]

To throw another option into the mix - I'd given some thought to placing an intrathecal catheter for the case instead. Opinions re: epidural vs intrathecal catheter for lower extremity vascular cases in significantly co-morbid patients?

Both techniques will work. An epidural catheter maybe easier to titrate and nursing floors are usually more familiar with it than with an intrathecal catheter.

 

[Arch Guillotti]

I don't trust anyone other than myself or someone I have browbeat to death to manage an intrathecal catheter.

Both techniques will work. An epidural catheter maybe easier to titrate and nursing floors are usually more familiar with it than with an intrathecal catheter.

 

[IN2B8R]

I don't trust anyone other than myself or someone I have browbeat to death to manage an intrathecal catheter.

Amen to that.