National Board Ex- 6 Book .pmd - National Board Of Examination

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llPatients receiving heparin forgreater than 4 days shouldhave platelets assessed priorto neuraxial block andcatheter removal because ofthe risk of heparin inducedthrombocytopenia.Intraoperative coagulationwith heparin during vascularsurgery with neuraxialtechniques. 5-10,000 unitsof heparin are givenintraoperatively duringvascular surgery to preventcoagulation during crossclamping of arterial vessels.In such patients. Avoidadministering a centrineuraxialblock in patients withother coexisting coagulopathies.Delay heparinadministration for one hourafter needle placement.Indwelling epidural cathetersshould be removed 2-4 hoursafter last heparin dose andafter assessing the patient’scoagulation status and reheparinizationshould bedone 1 hr after catheterremoval. Monitor the patientpostoperatively to provideearly detection of motorblockade. Although blood onneedle or catheter or evendifficult needle placementmay increase risk of spinalhaematomas, there is no datato support cancellation of thecase. Direct discussion withthe surgeon and assessmentof risk benefit ratio iswarranted.Full Anticoagulation ofcardiac surgery with neuraxialtechniques-Currentlyinsufficient data is available todetermine risk of neuraxialhaematomas with fullanticoagulation of cardiacsurgery. The use of thoracicepidural analgesia duringcardiac bypass surgeryremains controversialbecause of the risk of spinalcord damage from anepidural haematomas.Current Recommendationsfor Regional AnaestheticManagement ofLMWHPreoperative LMWHl Patients on LMWHthrombophylaxis they havean altered coagulation profileand therefore needle placementshould be done 10-12hours after the LMWH dose.l In patients on higher doses ofLMWH for treatment ofacute coronary syndromesand venous thromboembolisme.g. enoxaparin 1.5mg/kg daily, enoxaparin1mg/kg twice daily etc. willrequire delay of at least 24 hrsto assume normal hemostasisat the time of needleinsertion.l Neuraxial techniques shouldbe avoided in patientsadministered a dose ofLMWH 2 hrs preoperatively(general surgery) because atthis time peak anticoagulantactivity occurs.Post operative LMWH -patients with postoperativeinitiation of LMWH cansafely undergo singleinjection and continuouscatheter techniques.l Twice daily dosing - Thistechnique is associated withan increased risk of spinalhaematomas. The first dose isgiven not earlier than24 hours postoperativelyregardless of anaesthetictechnique. Epidural cathetersshould be removed prior toinitiation of thromboprophylaxis.If a continuoustechnique is selected, theepidural catheter can be leftin situ overnight, removed thefollowing day & LMWHadministered 2 hours aftercatheter removal.l Single daily dosing- Thefirst LMWH dose should beadministered 6-8 hourspostoperatively, next dose 24hours later. Indwellingneuraxial catheters may besafely maintained, howeverthe catheter should beremoved 10-12 hours afterthe last dose of LMWH.Subsequent LMWH shouldoccur 2 hours after catheterremoval. The presence ofblood during needle &catheter placement shouldresult in delay of initiation ofLMWH for 24 hourspostoperatively.Regional Anaesthetic Managementof the patient on Oralanticoagulantsl The management of patientsreceiving warfarin remainscontroversial. For a regionalblock to be performed theanticoagulant must bestopped (ideally 4-5 days priorto the procedure) and thePT/INR measured prior toinitiation of the block.neuraxial block. Early afterdiscontinuation of warfarin48Journal of Postgraduate Medical Education, Training & ResearchVol. II, No. 5, September-October 2007
PT/INR predominantlyreflects factor VII levels.Despite acceptable factor VIIlevels adequate levels of II,IX and X may not be presentuntil the PT/INR is withinlimits.l For patients receiving aninitial dose of warfarin priorto surgery, the PT/INRshould be checked prior toneuraxial block if the firstdose was given more than 24hours earlier or a second doseof oral anticoagulants hasbeen administered.l Patients given low-dosewarfarin (5mg mean dailydose) should have PT/INRmonitored on a daily basisand checked before catheterremoval. The catheter shouldbe removed when the INR is
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