epidural catheter removal and platelets.

[BLADEMDA]

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.

KISS

1. Why use an 17 or 18 gauge tuohy needle and risk a massive PDPH (if you get a wet tap) instead of a 25 gauge non cutting needle utilizing an SAB
2. Failure rates are higher with epidurals vs single shot spinals (every study has confirmed this fact)
3. The Risk of a postop epidural hematoma while very low is even lower with a single shot spinal
4. Platelet count near 100,000- Again all our literature shows a non cutting needle allows one to perform neuraxial techniques safely with low platelet counts even as low as 50,000. This provides a "buffer" when choosing a single shot spinal approach.
5. Increased risk of infection at the site of the epidural puncture vs a single shot spinal
6. Dealing with issues related to the epidural while it is in the patient. This means more phone calls and issues
7. Post op Anti-coagulation- some surgeons start these drugs the next morning after surgery. Do you want an epidural catheter in place?

I would either do a single shot spinal or a general anesthetic on this patient. In my practice, an epidural for total joints simply isn't on the radar.

KISS

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[Twiggidy]

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.

3....i place and remove OB catheters with levels at or near 70.

What's the difference between 64 and 70? .....6......jk. In all honesty, you'd probably be fine at 64 pulling because as you said, the patient isn't oozing.

 

[Twiggidy]

I don't do much other anymore, which actually may be stalling my career, therefore, I have a question....

Are most of you guys doing knees doing femoral nerve blocks as a replacement to epidural or single shot opioid, or nothing? Just curious

 

[BLADEMDA]

I don't do much other anymore, which actually may be stalling my career, therefore, I have a question....

Are most of you guys doing knees doing femoral nerve blocks as a replacement to epidural or single shot opioid, or nothing? Just curious

My practice is surgeon preference:

1. Some get Femoral plus iPack blocks
2. Some get Adductor canal plus iPack blocks
3. Some get just Adductor canal blocks plus LIA
4. A few get SAB with 100 ugs of duramorph plus Adductor canal blocks

Nobody gets a Femoral and Sciatic block any longer for a total knee replacement.

 

[deleted682700]

Thanks for this MOCA minutes