Epidural and unfractionated heparin

Started by jafo1964, December 02, 2007, 05:06:00 PM

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jafo1964

40 year old peripheral vascular disease patient was posted for femoro-popliteal bypass.
anaesthetic plan was
sequential combined spinal epidural - 2 needle, 2 interspace technique
Epidural was performed in L3L4 ISS and catheter was placed cephalad - 6 cms.
Epidural vein was cannulated - free flow of blood in catheter
Catheter withdrawn each centimeter and negative aspiration performed
At 4 cms into space no free flow of blood seen
Test dose given - No rise in HR seen -  catheter assumed to be in epidural space
SUCCESSFUL but TRAUMATIC epidural catheter placement acheived
SAB done in L4L5 ISS with 3.5 ml of hyperbaric bupivacaine
Surgery started
NOW THE DILEMMA
2 hours into surgery, as is routine in vascular cases, surgeon wants 5000 IU unfractionated heparin. Additional repeated doses may be needed

ASRA recommendations advice avoiding anticoagulants after traumatic epidural  for 24 hours if possible or weighing of risk - benefit ratio in such a scenario.
Would like to hear opinion of people who have been stuck in similar conflicting scenario

regards

yogenbhatt1

Hi,
Yes, a lot is written about epidural hematomas and recorded too. I gave an epidural in a pt of 76 yr age. I kept wondering why she had so much bleeding from skin puncture of Epidural. There was also frank blood in the catheter. We accepted when the saline wash was clear. To our disbelief the sister in OT asked as about the pint that that was going.
    We had finished it. She said, that pint had 5000 IU of Heparin. We by error ( Unlabelled) finished it while giving the epidural. That pint was made by ICCU staff for maintaining CVP cath.Imagine 5000 IU Heparin over 20 mins.
   To our good luck nothing happened to the patient. She was discharged on 7 th day and lived for next about a year.
May be it was pure luck.
I hope it supports you too.

Krishnendu Chaudhuri

There is no dilemma. As you yourself state "ASRA recommendations advice avoiding anticoagulants after traumatic epidural  for 24 hours if possible or weighing of risk - benefit ratio in such a scenario." Weighing the risk an epidural haematoma against the near certainty of a graft shutdown with the patient losing a leg, I'd choose to give the heparin. However I admit it's not a choice I'd like to have to make. Luck would definetely play a major role