Neuraxial blocks 5 Flashcards
You are called to remove an epidural catheter form a patient receiving enoxaparin for DVT prophylaxis. According to the consensus statement from the American Society for Regional Anesthesia and Pain medicine, what is the MOST appropriate course of action?
a. hold enoxaparin for six hours, pull catheter, then restart enoxaparin one hour later
b. hold enoxaparin for 12 hours, pull catheter, then restart enoxaparin four hours later
c. hold enoxaparin for 24 hours, pull catheter, then restart enoxaparin two hours later
d. order a hematology consult
B.
The risk of________________ is similar during block placement and catheter removal
epidural hematoma
Epidural hematoma can cause
paralysis
________________within eight hours of epidural hematoma offers the best chance of recovery
surgical decompression
Presenting symptoms of epidural hematoma include
lower extremity weakness, numbness, low back pain, and bowel and bladder dysfunction
These patients present with a difficult situation in terms of holding vs. continuing antiocoagulation.
patients with cardiac stents
Describe the recommendations for a patient who is on Cox-1 inhibitors (NSAIDs, aspirin).
if clinical assessment of coagulation status appears normal and no other blood thinners in use then no added risk or limitations
Describe the recommendations for a patient who is on glycoprotein IIb/IIIa antagonists (abciximab, tirofiban).
avoid until platelet function has recovered
-before block placement: hold 4-8 hr for Tirofiban and eptifibatide ; hold 24-48 hour for abciximab
contraindicated to not restart within 4 weeks of surgery
Describe how long clopidogrel should be held prior to block placement.
hold 5-7 days
may restart 24 hours postop
Describe how long prasugrel should be held prior to block placement
hold 7-10 days
may restart 24 hours postop
Describe how long ticlopidine should be held prior to block placement
hold 10 days
may restart 24 hours postop
Describe how long unfractionated heparin must be held prior to block placement
low dose 5,000 U up to TID: hold 4-6 hour
higher dose <20,000 U daily: hold 12 hour
Therapeutic high dose: hold 24 hour
Criteria to consider for a patient on heparin when placing or removing a neuraxial catheter is
obtain a platelet count prior if on IV or SQ heparin >4 days
How quickly can heparin be restarted after block placement?
1 hour
After neuraxial catheter removal, how long should heparin be held for?
held 4-6 hours after last SQ dose
held 4-6 hour after IV infusion discontinued
What drugs are an absolute contraindication to neuraxial anesthesia?
thrombolytic agents such as TPA, streptokinase, alteplase, urokinase
Is neuraxial anesthesia safe to perform for patients taking herbal therapies such as garlic, ginkgo, and ginseng, that inhibit platelet aggregation?
yes, proceed if patient is not taking other blood thinning drugs
Describe the recommendations for anti-vitamin K drugs such as warfarin.
before block/catheter placement: hold warfarin for 5 days, verify normal INR
neuraxial catheter removal: wait until INR <1.5
Describe considerations for before block/catheter placement when patient is on low molecular weight heparin.
delay at least 12 hr after prophylactic dose
delay at least 24 hour after therapeutic dose & consider checking anti-factor 10a activity in elderly or if renal insufficiency
Describe when it is acceptable to restart LMWH after block/catheter placement.
delay first dose at least 12 hours after block
if single daily dosing, give 2nd dose no sooner than 24 hours after 1st dose
If you have blood in the needle or catheter of a patient on LMWH,
delay initiating LMWH for 24 hour
When removing a neuraxial catheter for a patient on LMWH,
remove before initiating LMWH if possible; delay 1st dose at least 4 hr after removal
otherwise, remove at least 12 hr. after last dose; hold for 4 hr after removal
Describe considerations for oral anti-factor 10a agents prior to block/catheter placement.
discontinue at least 72 hours (3 days) before the block
consider checking drug level or anti-factor 10a activity if <72 hours
When removing a neuraxial catheter for patients on oral anti-factor 10a agents,
remove 6 hours before the 1st postoperative dose
if accidental dose given with catheter in situ, hold subsequent dose before catheter removal for >20 hours
Which factors increase the risk of postdural puncture headache?
a. pitkin needle
b. needle perpendicular to the long-axis of the neuraxis
c. early ambulation
d. continuous spinal catheter
A & b
Describe the factors that contribute to PDPH.
puncturing the dura causes CSF to leak from the SAH
as CSF pressure is lost, the cerebral vessels dilate
the brainstem sags into the foramen magnum which stretches the meninges and pulls on the tentorium