epidural catheter removal and platelets.

[epidural man]

I know...we have had this discussion before.

Anyway.

Clinical scenario -
Patient with history x 2 of DVT (I think one was also a PE) and on Coumadin....bridged to lovenox for Knee replacement.

Epidural placed with platelets 102.

Day one - platelets, 64 at 4am. Surgeons are anxious to start Lovenox - therapeutic dosing. Recheck of platelets at noon - 70.

Decision time. I'm sure there are lots of different ways to do this - but here where the options I thought I should decide on. Please share opinion on what you would do. Granted - I could suggest dosing to surgeons, but certainly - they could do what they wanted - but I think they would go along with my opinion.

1. Leave catheter in place. Dose Lovenox at prophylactic dose. Recheck PLT - hold Lovenox for 12 hours, to pull when PLT return to 100.

2. Leave catheter in place. Dose lovenox at therapeutic dose. recheck PLT - hold lovenox for 24 hours to pull catheter once PLT above 100.

3. Pull catheter now. PLT seem to be holding steady. They likely work since the patient isn't bleeding. Lovenox after pulling in a few hours

4. Give PLTs. re-check - pull after the number is up.

I'll tell you what we did after I get some opinions.

But - c0mpeting risks right? PLT transfusion - risks and costs with that. Not anti-coagulating - this is a HIGH RISK patient....risks with that. Pulling catheter with this plt level - has some risk with serious consequences, etc.

---

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[Infexious]

I would say 3. If you are feeling really anxious, check a TEG for confirmation of functioning PLTs and then pull.


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[Urzuz]

3.
Out of curiosity why did you put an epidural in to begin with?

 

[epidural man]

3.
Out of curiosity why did you put an epidural in to begin with?

I didn't make that decision (but I would have placed if it WAS my decision).

But are you asking a general question about the value of epidural anesthesia perioperatively in a total joint? Or why put it in with someone with a PLT of 102?

 

[partydoc]

1

 

[deleted171991]

I know...we have had this discussion before.

Anyway.

Clinical scenario -
Patient with history x 2 of DVT (I think one was also a PE) and on Coumadin....bridged to lovenox for Knee replacement.

Epidural placed with platelets 102.

Day one - platelets, 64 at 4am. Surgeons are anxious to start Lovenox - therapeutic dosing. Recheck of platelets at noon - 70.

Decision time. I'm sure there are lots of different ways to do this - but here where the options I thought I should decide on. Please share opinion on what you would do. Granted - I could suggest dosing to surgeons, but certainly - they could do what they wanted - but I think they would go along with my opinion.

1. Leave catheter in place. Dose Lovenox at prophylactic dose. Recheck PLT - hold Lovenox for 12 hours, to pull when PLT return to 100.

2. Leave catheter in place. Dose lovenox at therapeutic dose. recheck PLT - hold lovenox for 24 hours to pull catheter once PLT above 100.

3. Pull catheter now. PLT seem to be holding steady. They likely work since the patient isn't bleeding. Lovenox after pulling in a few hours

4. Give PLTs. re-check - pull after the number is up.

I'll tell you what we did after I get some opinions.

But - c0mpeting risks right? PLT transfusion - risks and costs with that. Not anti-coagulating - this is a HIGH RISK patient....risks with that. Pulling catheter with this plt level - has some risk with serious consequences, etc.

Get a TEG. Also, even with Lovenox, consider HIT. Why are the platelets dropping?

 

[epidural man]

Get a TEG.

This would be nice. TEG with platelet mapping.

 

[deleted171991]

This would be nice. TEG with platelet mapping.

One can have low platelets and normal coagulation, especially if fibrinogen is high. Also, I don't know how much the low platelets impact coagulation in a hypercoagulable patient.

Without a TEG, my vote goes to finding out why the platelets are dropping. If not HIT, give platelets, recheck, and pull the catheter, then restart Lovenox after the appropriate number of hours.

 

[Urzuz]

I didn't make that decision (but I would have placed if it WAS my decision).

But are you asking a general question about the value of epidural anesthesia perioperatively in a total joint? Or why put it in with someone with a PLT of 102?

The value of an epidural in a routine total joint.

Just wondering what a normal patient's trajectory is and how you utilize the epidural. How long are they in the hospital for? When do they start ambulating? What type of local do you use in the mix? etc

 

[epidural man]

The value of an epidural in a routine total joint.

Just wondering what a normal patient's trajectory is and how you utilize the epidural. How long are they in the hospital for? When do they start ambulating? What type of local do you use in the mix? etc

Short answer - we believe in the propensity matched data sets that say neuraxial anesthesia is beneficial in joint replacement surgeries.

Our usual pathway is Combined spinal/epidural without GA if possible - catheter stays in one day - removed in the morning, Anti-coagulation started after catheter removal. Walk this day. Surgeons use Exparel around the knee capsule for unilateral. For bilateral knees, we do adductor canal blocks with Exparel/bupivacaine (hopefully after epidural comes out). I don't know how long they stay.

0.125% bupivacaine in the epidural for major joints.

 

[Planktonmd]

I would pull the catheter out before starting Lovenox in this case.

 

[pgg]

Our usual pathway is Combined spinal/epidural without GA if possible - catheter stays in one day - removed in the morning,

Is this because your surgeons are terrible/slow and you frequently need the E part of the CSE for the surgical anesthetic, or is the epidural placed with the primary intent that it will be used for postop pain?

Because the latter is weird.

 

[Noyac]

I would not have placed the epidural even if the plts were 300.

 

[risnwb]

Number 3.


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[IlDestriero]

3


--
Il Destriero

 

[Arch Guillotti]

I would not have placed the epidural even if the plts were 300.

Why not?

 

[deleted171991]

Short answer - we believe in the propensity matched data sets that say neuraxial anesthesia is beneficial in joint replacement surgeries.

Anything less than multiple large randomized controlled trials is unreliable when comparing outcomes. Even those can be mistaken. I would be very careful before developing protocols based on statistically-"engineered" retrospective studies. We've seen it time and again in critical care. Editors don't publish studies that don't find a statistical difference, hence people manipulate the data until they produce one; it's like the proliferation of fake news with bombastic titles on the Internet. Any benefit that cannot be easily reproduced and confirmed by a lot of people is probably nonexistent.

It's one thing to establish a standard consistent way of skinning the cat for the entire group. It's a completely different story to call it "science".

P.S. There should be a law limiting the use and interpretation of statistical studies to Math grads.

 

[deleted162650]

Short answer - we believe in the propensity matched data sets that say neuraxial anesthesia is beneficial in joint replacement surgeries.

Our usual pathway is Combined spinal/epidural without GA if possible - catheter stays in one day - removed in the morning, Anti-coagulation started after catheter removal. Walk this day. Surgeons use Exparel around the knee capsule for unilateral. For bilateral knees, we do adductor canal blocks with Exparel/bupivacaine (hopefully after epidural comes out). I don't know how long they stay.

0.125% bupivacaine in the epidural for major joints.

That's a very old fashioned way to do things. SS SAB (15mg of iso bupi will last long enough even for slow Navy surgeons). No regional for hips as they really aren't that painful and ambulate same day. Knees get peripheral blocks ranging from ACB only to fem + pop depending on local culture and how hard surgeons push same day ambulation. This way no need to worry about coag/anticoag issues and pt isn't chained to their bed by a little 19g catheter.

The military is supposed to be on the cutting edge of regional Anes but this is an early 2000's way to do things.

 

[BLADEMDA]

That's a very old fashioned way to do things. SS SAB (15mg of iso bupi will last long enough even for slow Navy surgeons). No regional for hips as they really aren't that painful and ambulate same day. Knees get peripheral blocks ranging from ACB only to fem + pop depending on local culture and how hard surgeons push same day ambulation. This way no need to worry about coag/anticoag issues and pt isn't chained to their bed by a little 19g catheter.

The military is supposed to be on the cutting edge of regional Anes but this is an early 2000's way to do things.

FYI, tetracaine with epi for a single shot SAB will last over 7 hours. Even a Navy Ortho surgeon can finish a total joint in that time frame. There simply is no need for epidural catheters any longer in total joint cases and I haven't used one in 10+ years.

 

[deleted171991]

FYI, tetracaine with epi for a single shot SAB will last over 7 hours. Even a Navy Ortho surgeon can finish a total joint in that time frame. There simply is no need for epidural catheters any longer in total joint cases and I haven't used one in 10+ years.

Yes, but the studies...

 

[epidural man]

So most of you think that those that are placing epidurals are total joints are not using good clinical judgement?

I'm curious, what do you think the percentage of institutions that used to place epidurals aren't now?

Also, what has changed (besides earlier ambulation) in the last 15 years that now have trumped the advantages of epidural? Where we wrong and there are absolutely no advantages to epidural?

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Please share with me some of the newer better quality non retrospective data that shows epidurals cause harm or are clearly inferior. Let's start with FFP, then give pgg a shot, then top it of with BLADE.

 

[deleted162650]

So most of you think that those that are placing epidurals are total joints are not using good clinical judgement?

I'm curious, what do you think the percentage of institutions that used to place epidurals aren't now?

Also, what has changed (besides earlier ambulation) in the last 15 years that now have trumped the advantages of epidural? Where we wrong and there are absolutely no advantages to epidural?

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Please share with me some of the newer better quality non retrospective data that shows epidurals cause harm or are clearly inferior. Let's start with FFP, then give pgg a shot, then top it of with BLADE.

So you're looking for some new crappy studies to show that no epidural is better than the crappy studies you have saying it is better??

Look, this is a common sense thing, not an academic scientific thing. An epidural is more invasive, more headache, and carries with it more side-effects than alternative methods which provide equivalent analgesia and while preserving motor function (of at least the opposite leg of not both) and no autonomic effects. How 'bout you tell us why you think an epidural is superior since you are clearly in the minority's here.

 

[epidural man]

So you're looking for some new crappy studies to show that no epidural is better than the crappy studies you have saying it is better??

Look, this is a common sense thing, not an academic scientific thing. An epidural is more invasive, more headache, and carries with it more side-effects than alternative methods which provide equivalent analgesia and while preserving motor function (of at least the opposite leg of not both) and no autonomic effects. How 'bout you tell us why you think an epidural is superior since you are clearly in the minority's here.

No. this thread had nothing to do about the value of epidurals. Other people brought it up. And by the way, I almost always want to be in the minority in everything I do. I think Robert Frost was on to something. I think majorities are often wrong and misguided.

 

[Planktonmd]

An epidural was and will remain a reasonable way to manage post-op pain after joint replacement, it is just more labor intensive than other approaches like peripheral nerve blocks and/or surgeon peri-articular infiltration.
Many people don't do them anymore because they don't want to worry about the timing of anticoagulation, or deal with hypotension and other epidural issues.

 

[Noyac]

Why not?

Because I don't think epidurals are the way to go for joints. We don't need to achieve multiple days of pain management. These pts should be on p.o. Meds and participating fully in PT On POD #1 if not POD #0.
An epidural just isn't necessary in today's total joint care.

 

[Noyac]

I tried to edit my last comment.
After reading Epidural Man's approach, I feel like it is an acceptable one. However, I feel like it is overkill too. We do spinal she for all joints that are candidates which is probably over 90%. Of those, very very few get a general. We also do blocks which are anesthesiologist and surgeon dependent.

 

[Noyac]

That's a very old fashioned way to do things. SS SAB (15mg of iso bupi will last long enough even for slow Navy surgeons). No regional for hips as they really aren't that painful and ambulate same day. Knees get peripheral blocks ranging from ACB only to fem + pop depending on local culture and how hard surgeons push same day ambulation. This way no need to worry about coag/anticoag issues and pt isn't chained to their bed by a little 19g catheter.

The military is supposed to be on the cutting edge of regional Anes but this is an early 2000's way to do things.

Exactly.

 

[Noyac]

Also, Epidural Man, if you didn't have an epidural in place you wouldn't be in the position you find yourself in now. We are using more and more anticoagulant pts these days. Why place a catheter in these pts when it isn't superior.
You have heard of the KISS

 

[Hoya11]

I know...we have had this discussion before.

Anyway.

Clinical scenario -
Patient with history x 2 of DVT (I think one was also a PE) and on Coumadin....bridged to lovenox for Knee replacement.

Epidural placed with platelets 102.

Day one - platelets, 64 at 4am. Surgeons are anxious to start Lovenox - therapeutic dosing. Recheck of platelets at noon - 70.

Decision time. I'm sure there are lots of different ways to do this - but here where the options I thought I should decide on. Please share opinion on what you would do. Granted - I could suggest dosing to surgeons, but certainly - they could do what they wanted - but I think they would go along with my opinion.

1. Leave catheter in place. Dose Lovenox at prophylactic dose. Recheck PLT - hold Lovenox for 12 hours, to pull when PLT return to 100.

2. Leave catheter in place. Dose lovenox at therapeutic dose. recheck PLT - hold lovenox for 24 hours to pull catheter once PLT above 100.

3. Pull catheter now. PLT seem to be holding steady. They likely work since the patient isn't bleeding. Lovenox after pulling in a few hours

4. Give PLTs. re-check - pull after the number is up.

I'll tell you what we did after I get some opinions.

But - c0mpeting risks right? PLT transfusion - risks and costs with that. Not anti-coagulating - this is a HIGH RISK patient....risks with that. Pulling catheter with this plt level - has some risk with serious consequences, etc.

I would give platelets. Recheck, pull the catheter. This would be on the same day (same morning). They can start lovenox 2 hrs after that.

I think an epidural catheter is nice for post op pain. But would you want one placed in you preop, awake/sedated ? not at all... either spinal or blocks plus GA..

Epidural is especially a bad choice for this case. You have so many other options for analgesia with TKRs, why would you elect for an epidural and a catheter in a patient with plts 102 who is going to need aggressive post op anticoagulation? The epidural may be the routine at your place, which is not crazy IMO and would be superior pain control (to hell with early ambulation), but you have to know when to deviate from the protocol. If i saw PLTs 102 with the plan to anticoagulate aggressively post op I would change my plan from epidural to something else, no brainer.

 

[deleted171991]

So most of you think that those that are placing epidurals are total joints are not using good clinical judgement?

I'm curious, what do you think the percentage of institutions that used to place epidurals aren't now?

Also, what has changed (besides earlier ambulation) in the last 15 years that now have trumped the advantages of epidural? Where we wrong and there are absolutely no advantages to epidural?

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Please share with me some of the newer better quality non retrospective data that shows epidurals cause harm or are clearly inferior. Let's start with FFP, then give pgg a shot, then top it of with BLADE.

I wasn't arguing about your choice. There is more than one way to skin a cat, and I strongly believe that one should practice the safest anesthesia one is comfortable with.

I was arguing about the reasons for your choice. I see too many (ICU) protocols based on weak data, so it pushed a button. Nothing personal; I wasn't criticizing you. It's just that I don't remember any good RCTs about this, and anything else is almost hearsay nowadays. That's why Ioannidis suggests that most of our research is crap, and that's why most of our studies will never be reproduced by others (even some of the RCTs). I got pissed seeing another protocol based on debatable science.

Specifically to this case, I would have not put in a catheter with borderline platelets and the already known anticoagulation issues. Just not worth the headache. But I'm a minimalist and, as I said, it's your choice. I just can't stand a bad protocol that pushes docs into doing stuff.

 

[pgg]

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Noyac and Planktonmd summed up my feelings on epidurals for TKA postop pain control nicely. In general, nothing wrong with it, but wouldn't be my preference.

I think placing an epidural in this particular person with 102 platelets when you knew there was a significant risk of finding yourself in this postop thrombocytopenic Lovenox epidural conundrum was foolish. IMO at least 61% of being a good anesthesiologist is avoiding drama, not walking into it so you can cleverly get out of it.

And by the way, I almost always want to be in the minority in everything I do. I think Robert Frost was on to something.

I think a poet would need to write Vogon-grade poetry before being associated with an outcome bad enough to entice a plaintiff's attorney.

 

[BLADEMDA]

So most of you think that those that are placing epidurals are total joints are not using good clinical judgement?

I'm curious, what do you think the percentage of institutions that used to place epidurals aren't now?

Also, what has changed (besides earlier ambulation) in the last 15 years that now have trumped the advantages of epidural? Where we wrong and there are absolutely no advantages to epidural?

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Please share with me some of the newer better quality non retrospective data that shows epidurals cause harm or are clearly inferior. Let's start with FFP, then give pgg a shot, then top it of with BLADE.

The Epidural technique just isn't needed any longer. We have better approaches to total joints than that antiquated technique. Of course, the technique itself is sound and works just fine. But, for post op pain relief we have Peripheral nerve blocks (single shot or a catheter for the deluxe version). This allows anti-coagulation to occur the next day after surgery without any anesthetic related issues. The goal is ambulation on POD zero or POD1 and the epidural simply isn't the best choice any longer.

http://ether.stanford.edu/Ortho/protocol.html

 

[BLADEMDA]

 

[Scotty_G]

Not much to add as I agree epidural is not really needed even if you are working in an academic setting. Even without a PNB patients will get periarticular injection from the surgeon. Just get the catheter out now before things could potentially get worse and send for HIT.

 

[epidural man]

So just to follow up,

I pulled the catheter - then frequent neuro checks.

 

[sigrhoillusion]

So just to follow up,

I pulled the catheter - then frequent neuro checks.

How frequently? And who was doing them? You or nursing?

 

[fakin' the funk]

I'm a little shocked at the strong and very emphatic disdain for epidurals post for total joints.

Please share with me some of the newer better quality non retrospective data that shows epidurals cause harm or are clearly inferior. Let's start with FFP, then give pgg a shot, then top it of with BLADE.

No respect?

Here's my study: epidurals in unilateral TKAs don't pass the sniff or eyeball test. They're not necessary. None of the unilateral TKAs at my institution get epidurals. Vast majority are isobaric bupivacaine spinal +/- fentanyl, propofol sedation, adductor canal blocks (which are not amazing blocks anyway), "simple" local infiltration by surgeon, IV APAP/ketorolac postop. Ambulating late on POD#0.

Why is the epidural required again?

 

[facted]

Totally agree that most are moving away from post-op epidural for total joints to improve early ambulation, urinary retention, etc... We are doing duramorph spinals + ACB catheters at my insitution for TKR and spinal + single shot QL for THR.

Interestingly, though, I don't know of any study that shows spinal/block to be better than epidurals. In fact, the cochrane review from 2014 found the two techniques to be similar in terms of pain scores with lower N/V scores for block (not suprising). Satisfaction was actually higher in the epidural group. http://www.cochrane.org/CD009941/AN...operative-pain-after-knee-replacement-surgery

 

[sevoflurane]

So just to follow up,

I pulled the catheter - then frequent neuro checks.

Hey man. Rough crowd. Don't sweat it and thanks for posting.

 

[deleted171991]

Hey man. Rough crowd. Don't sweat it and thanks for posting.

Hear, hear!

 

[epidural man]

How frequently? And who was doing them? You or nursing?

the patient....gave excellent instructions. Did I do wrong?

 

[pgg]

I pulled the catheter - then frequent neuro checks.

Sounds good.

the patient....gave excellent instructions. Did I do wrong?

Are you messing with us, or what?!?


When doctors say "frequent neuro checks" it's understood by 99% of doctor-listeners that they mean checks by someone who knows what a neuro exam is.

You're concerned enough about the patient to do the checks in the first place, right? But you're unconcerned enough to leave it up to the patient? When the feared complication (albeit rare/unlikely) is spinal cord ischemia, something that needs to be handled with stat surgical decompression, you're going to leave it up to the patient's opiate-addled judgment and understanding of your excellent instructions, lack of denial, inexperience, to detect the problem and notify someone promptly?


I get the feeling you started this thread as bait for a discussion you wanted to have, but never got around to having, because it derailed into a swirl of disbelief that someone out there is doing epidurals for TKAs ...

Out with it, already! What do you really want to discuss here?

 

[BLADEMDA]

The odds were overwhelmingly in your favor of just pulling this catheter and not having a complication. I'm not advocating this on a routine basis but the risk was still small that anything bad like a hematoma would occur.

https://www.ncbi.nlm.nih.gov/pubmed/21451439

http://www.newswise.com/articles/ne...-anesthesia-in-women-with-low-platelet-counts

 

[Arch Guillotti]

[QUOTE="facted, post: 18404999, member: 237229"Interestingly, though, I don't know of any study that shows spinal/block to be better than epidurals. In fact, the cochrane review from 2014 found the two techniques to be similar in terms of pain scores with lower N/V scores for block (not suprising). Satisfaction was actually higher in the epidural group. http://www.cochrane.org/CD009941/AN...operative-pain-after-knee-replacement-surgery[/QUOTE]

Yeah but the SDN brain trust says that they are dumb and that we shouldn't do them.

 

[Arch Guillotti]

I think placing an epidural in this particular person with 102 platelets when you knew there was a significant risk of finding yourself in this postop thrombocytopenic Lovenox epidural conundrum was foolish. IMO at least 61% of being a good anesthesiologist is avoiding drama, not walking into it so you can cleverly get out of it.

Why do you expect the patient to be thrombocytopenic postop?

 

[BLADEMDA]

[QUOTE="facted, post: 18404999, member: 237229"Interestingly, though, I don't know of any study that shows spinal/block to be better than epidurals. In fact, the cochrane review from 2014 found the two techniques to be similar in terms of pain scores with lower N/V scores for block (not suprising). Satisfaction was actually higher in the epidural group. http://www.cochrane.org/CD009941/AN...operative-pain-after-knee-replacement-surgery

Yeah but the SDN brain trust says that they are dumb and that we shouldn't do them.[/QUOTE]

Just not needed any longer. It's an antiquated technique whose time has come and gone for routine cases. Sure, a small minority's still use an epidural technique but most of them have been doing that for 2 plus decades typically in an academic setting.

 

[Arch Guillotti]

Just not needed any longer. It's an antiquated technique whose time has come and gone for routine cases. Sure, a small minority's still use an epidural technique but most of them have been doing that for 2 plus decades typically in an academic setting.

Slim, I agree with you here. I'm not going to get into a pissing match with an orthopod over it though.

 

[pgg]

Why do you expect the patient to be thrombocytopenic postop?

I don't necessarily expect it, but odds of it happening are higher than normal. Borderline low to start with no real explanation, on heparin (raising the possibility of HIT).

I don't see the up side to an epidural.

 

[Arch Guillotti]

I think placing an epidural in this particular person with 102 platelets when you knew there was a significant risk of finding yourself in this postop thrombocytopenic Lovenox epidural conundrum was foolish.

I don't necessarily expect it, but odds of it happening are higher than normal. Borderline low to start with no real explanation, on heparin (raising the possibility of HIT).

I think you are saying two different things here

 

[pgg]

I think you are saying two different things here

Perhaps there's a difference in tone, but the message is the same.

No one should've been surprised that this patient was thrombocytopenic postop. I'm convinced that the essence of good anesthesia is looking like you're doing nothing at all, and putting a 1000% elective epidural in someone who had decent odds of being under 100 postop (plus the surgeons' known anticoagulation regimen) necessitating this pull/not-pull decision +/- frequent neuro checks is a whole lot of something.

Epidurals are definitely no longer the norm for postop TKA pain management, for lots of reasons. While they're certainly OK, in the sense that there are many acceptable and safe ways to do any anesthetic, they do carry baggage and issues that other techniques do not. I'm sticking with my opinion that the epidural was a bad idea, in this case.