American Society of Regional Anesthesia and Pain Medicine August 2017 - 19

Dr. Jacob: A midthoracic epidural would afford the greatest ability
to provide extended duration bilateral analgesia over multiple
levels with a single catheter technique. My greatest concern
would be placing a neuraxial catheter in a patient potentially
taking antiplatelet or anticoagulant medications. I am specifically
concerned about the risk for a neuraxial hematoma. He would
also be at risk for hypotension due to the sympathectomy from
the epidural block as well as the rare, but real, risk for neuraxial
infection and neurologic injury.
Multiple injection intercostal blocks would also be effective but
limited by a shorter duration of benefit even when using a longacting local anesthetic. Bleeding risk for intercostal block (even
in an anticoagulated patient) should be minimal as long as the
injection is performed away from the neuraxis in a compressible
site (eg, midaxillary line). By performing multiple intercostal blocks,
it would provide pain relief until the extended family arrives to
obtain additional medical history and would also help clarify
if his respiratory difficulty is indeed due to pain (secondary to
the fractures) versus some other cause. If his respiratory status
improves, then it provides stronger evidence that an extended
duration block from a thoracic epidural would be beneficial.
Dr. Blake: I have chosen multimodal analgesia +/- ketamine
infusion because I do not know the anticoagulation status of this
patient and he has a history that puts him at increased likelihood
of being on an anticoagulant. An epidural or paravertebral blocks
could be contraindicated if he is in fact on certain anticoagulants.
I believe that regional anesthesia may be superior for pain control,
but multimodal therapy can provide some pain control without the
risks posed by regional anesthesia in this situation. I have concerns
about administering opioids to this patient and I would try to avoid
them because they could further depress breathing or cause
delirium/mental status changes in this elderly patient. Ketamine
could contribute to pain control but may also potentially cause
confusion, hallucinations, or other dissociative side effects.
Dr. Rustameyer: My biggest concern with an epidural is the
coagulation status of a trauma patient with a history of a stroke.
Therefore, I would want to check prothrombin time (PT)/INR on
him prior to epidural placement. I would also need to get a more
complete medication list prior to placement. The benefits to an
epidural for bilateral rib fractures is that I can provide localized pain
control with minimal cognitive interaction of the medications.
Thirty minutes into your consult, the labs return on this patient and
reveal an INR of 1.4 and platelet count of 92K. All other values are
normal, including liver function tests. The surgical team knows
you have required a platelet count of 100K or higher for epidural
placement and offers to do a platelet transfusion if you think it is
necessary to proceed safely. They really want this block in and feel
it will help him tremendously.

3. Describe your analgesic and management plan for this
patient at this point along with justification for your
decisions (if it is the same as in Q1 just say "same").
Dr. Guha: I would ensure that the patient is not on any other
anticoagulants or antiplatelet agents, including aspirin or NSAIDs.
If not, I would still proceed with an epidural. If he is on other
anticoagulant medications, I would recommend a nonregional
technique, such as ketamine infusion and/or multimodal analgesia.
Dr. Gilloon: Same. They still have not verified the patient's
medication list. If the patient was on warfarin, his INR would need
to be normal prior to proceeding with an epidural or paravertebral
catheter. Even if the patient is not on warfarin, an elevated INR and
low platelet count pose an increased risk of bleeding.
Dr. Jacob: I would not initiate neuraxial analgesia with an INR of
1.4, nor would I advise anyone to initiate treatment to lower an INR
just to place an epidural. Therefore, I would proceed with multilevel
intercostal block plus multimodal analgesia.
Dr. Blake: Same. I still do not know if the patient is taking
any anticoagulants. The elevated INR could be the patient's
baseline, due to liver disease, or could indicate that the patient
is on warfarin. The marginally low platelet count, as well as the
somewhat elevated INR, puts the patient at some increased risk for
bleeding, so if he is on an anticoagulant as well, I would definitely
want to avoid an epidural or paravertebral block.
Dr. Rustameyer: With that platelet count, I would want to trend
his platelets prior to placing a neuraxial catheter. Therefore, in this
situation, I would keep him comfortable with multimodal analgesia
and check another platelet count in 2 hours.

American Society of Regional Anesthesia and Pain Medicine
2017

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Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2017

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http://www.brightcopy.net/allen/asra/18-04
http://www.brightcopy.net/allen/asra/18-3
http://www.brightcopy.net/allen/asra/18-2
http://www.brightcopy.net/allen/asra/18-1
http://www.brightcopy.net/allen/asra/17-4
http://www.brightcopy.net/allen/asra/17-3
http://www.brightcopy.net/allen/asra/17-2
http://www.brightcopy.net/allen/asra/17-1
http://www.brightcopy.net/allen/asra/16-4
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http://www.brightcopy.net/allen/asra/16-2
http://www.brightcopy.net/allen/asra/16-1
http://www.brightcopy.net/allen/asra/15-4
http://www.brightcopy.net/allen/asra/15-3
https://www.nxtbook.com/allen/asra/15-2
https://www.nxtbook.com/allen/asra/15-1
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