Epidural anesthesia, adult : Colligative - Practical Wisdom in Anesthesia, Surgery, and Medicine.

Jan 17, 2013

Aim for INR <1.5 at time of epidural catheter withdrawal. Neurologic assessment be continued for at least 24 hrs after catheter removal if warfarinised. ASRA guidelines 3rd Edition
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Jan 17, 2013

Bloody or traumatic tap during epidural or spinal insertion ?
- withold LMWH/clexane/enoxaparin for 24hrs. ASRA Guidelines 3rd Edition refl.in/c6

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Jan 17, 2013

For patients managed with unfractionated subcutaneous heparin dosing regimens of 5,000 units twice daily, there is no contraindication to neuraxial block. ASRA Guideline 3rd Edition refl.in/c9

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Mar 03, 2012

If clopidogrel has been given whilst a patient has an epidural in place discuss the options for timing of removal with the departmental director and haematologist.

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Jan 18, 2013

If a bloody tap occurs at the time of neuraxial block, discuss risk vs benefit with the surgeon & patient before proceeding with vascular surgery requiring full anticoagulation. ASRA Guidelines 3rd Edition refl.in/cc

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Oct 19, 2011

If INR > 3, warfarin dose be held or reduced in pts with indwelling neuraxial catheters. No recommendation on how to safely remove neuraxial catheters in pts with therapeutic levels of anticoagulation. ASRA Guidelines 3rd Edition refl.in/bz

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Aug 07, 2011

If patient has received LMWH/clexane/enoxaparin (therapeutic regimen eg 1mg/kg bd or 1.5mg/kg daily), wait 24hrs before placing neuraxial block. ASRA Guidelines 3rd Edition refl.in/c2

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Dec 06, 2012

Subtherapeutic anti Xa-level does not mean it is safe to proceed

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If recent fibrinolytics or thrombolytics have been administered, ASRA recommends against neuraxial blocks except in highly unusual circumstances. Data not available to clearly outline the length of time neuraxial puncture should be avoided. ASRA Guideline refl.in/cd

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Jan 18, 2013

If removing epidural with INR 1.5-3.0, do so with caution & ensure no other medications that interfere with clotting. Assess neurology before removal & monitor neurology after removal. ASRA Guidelines 3rd Edition refl.in/by

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Aug 07, 2011

If the patient has been administered unfractionated heparin for more than 4 days they are at risk of HITTS. Perform a platelet count prior to neuraxial block or catheter removal. ASRA Guidelines 3rd Edition refl.in/c8t h

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Feb 22, 2012

If the patient has received a dose of clopidogrel whilst an epidural catheter is in place, one option available (in consultation with a haematologist) is to wait 5 days and remove the epidural once some partial platelet function has returned, monitoring for signs of infection and removing it earlier if necessary with platelet cover. Oral antibiotic prophylaxis could be considered to reduce the risk of infection in the prolonged epidural placement.

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Dec 02, 2011

If the patient has recieved LMWH/clexane/enoxaparin (thromboprophylaxis regimen), wait 10-12 hrs after last dose before performing a neuraxial block. ASRA Guidelines 3rd Edition refl.in/c0

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Feb 24, 2012

If thrombolysis whilst epidural catheter in situ, no recommendation on course of action in the ASRA guidelines. Consider awaiting normalisation of fibrinogen. ASRA Guidelines 3rd Edition refl.in/cg

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Mar 03, 2012

If using intraoperative heparin: Monitor patient postoperatively to detect (early) motor blockade & consider use of low concentration local anesthetics to enhance early detection of motor deficits associated a spinal hematoma. #safety
ASRA Guidelines 3rd Edition refl.in/cb

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Dec 06, 2012

If using untraoperative unfractionated heparin, remove indwelling neuraxial catheters 2 to 4 hrs after the last heparin dose & assess the patient's coagulation status. ASRA Guidelines 3rd Edition refl.in/ca

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Mar 03, 2012

In patients who have received neuraxial blocks at/near time of fibrinolytic & thrombolytic therapy, commence neurological monitoring & use low concentration LA for early detection of motor block. ASRA Guidelines 3rd Edition refl.in/ch

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Aug 07, 2011

Injecting normal saline prior to feeding the epidural catheter may reduce the incidence of inadvertant intravenous catheter #ref

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Aug 31, 2011

Wait 1 hour after non-traumatic neuraxial block before administering therapeutic anticoagulation with unfractionated heparin. ASRA Guidelines 3rd Edition refl.in/c7

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Oct 17, 2011

Preoperative Optimisation

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Assessment, Workup

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Consent, Discussion

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Coordinating

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Medication management, Premed

Clopidogrel: Withhold therapy 7 days prior to neuraxial block ASRA Guidelines 3rd Edition refl.in/bu

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Aug 07, 2011

Glycoprotein IIb/IIIa inhibitors: Platelet function normal after 4 - 8 hrs (eptifibatide & tirofiban), 24 - 48 hrs (abciximab). ASRA Guidelines 3rd Edition refl.in/cf

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Aug 07, 2011

Heparin infusions should be discontinued 2-4 hrs before neuraxial catheter removal. Coagulation status assessed before manipulation of the catheter. Monitor neurology for at least 12 hrs after the catheter removal. ASRA Guidelines refl.in/cj

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Aug 07, 2011

NSAIDS - not contraindicated in neuraxial block, but their use should be taken into account in those patients with borderline platelet or clotting function. ASRA Guidelines 3rd Edition. refl.in/bw

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Aug 07, 2011

Warfarin/Coumadin: Withold 5 days preoperatively, and check INR on day of surgery prior to neuraxial block. No firm guideline for desirable INR. ASRA Guidelines 3rd Edition refl.in/c1

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Aug 07, 2011

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Equipment, Preparation

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Duration

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Anatomy

Anatomy relevant to epidural anaesthesia. refl.in/6f

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May 26, 2011

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IV access

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Monitoring

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Special drugs

Ticlopidine: Suggested time to withhold prior to neuraxial block is 14 days. ASRA Guidelines 3rd Edition refl.in/bv

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Apr 25, 2014

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Sep 11, 2015

Recommence LMWH/clexane/enoxaparin (thromboprophylaxis dosing) 6hrs postoperatively for standard daily regimen after neuraxial block. ASRA Guidelines 3rd Edition refl.in/c5

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Oct 11, 2011

Recommence thromboprophylactic dose of LMWH/clexane/enoxaparin 2 hrs after removal of catheter. ASRA Guidelines 3rd Edition refl.in/c3

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Oct 11, 2011

The usual epidural infusion rate range is 0.1 mL/kg/hr — 0.3 mL/kg/hr 0.125% levobupivacaine.
In NEONATES the maximum infusion rate is 0.2 mL/kg/hr of 0.125% levobupivacaine.
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May 11, 2012