American Society of Regional Anesthesia and Pain Medicine August 2017 - 20
there are fractures/instability in other areas, a technique may still
be performed as long as the patient is cleared for positioning,
such as sitting or log rolling. Our guidelines are not completely
standardized across our group. Some colleagues in my group are
less conservative than others, and we all tend to use our own
judgment at times. Our guidelines have been conveyed to our
surgical colleagues on numerous occasions, but since we are an
academic institution, we frequently have new residents that are not
aware of these guidelines, and they are not always conveyed by
faculty or senior level residents.
Dr. Rustameyer: None.
5. Would required coagulation parameters be different for a
paravertebral versus epidural catheter insertion?
Dr. Guha: No, the required coagulation parameters would be the
same for both regional techniques.
4. What institutional guidelines exist for placement of blocks
in trauma patients (eg, medication history, coagulation
parameters, spine clearance) for your practice? Are these
guidelines standardized across your group and conveyed to
surgical colleagues?
Dr. Guha: We do not commonly treat patients with rib fractures
at our institution. We do not have specific guidelines in place for
our institution regarding neuraxial techniques and anticoagulation.
Instead, we rely on ASRA guidelines, which we communicate to our
surgeons.
Dr. Gilloon: My group uses the ASRA guidelines from Regional
Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic
Therapy: American Society of Regional Anesthesia and Pain
Medicine Evidence-Based Guidelines, 3rd Edition to guide placement
of blocks. The exact platelet count threshold varies by physician
and clinical situation. We are a Level 3 trauma center and have a
robust Acute Pain Service; however, we are rarely consulted for rib
fracture analgesia management.
Dr. Gilloon: In my opinion, a paravertebral block is a deep plexus
block, and the same ASRA guidelines employed for epidural
catheters need to be applied.
Dr. Jacob: I would treat a paravertebral catheter identical to an
epidural catheter.
Dr. Blake: At our institution, we generally treat paravertebrals as a
neuraxial technique, so required coagulation parameters would be
the same as epidural catheter insertion.
Dr. Rustameyer: I would have the same coagulation parameters for
paravertebral and epidural catheter insertions. I treat them both as
neuraxial blocks.
A family member arrives for this patient, and she provides some
additional history: He is on aspirin 81 mg a day as a blood thinner,
insulin, and metoprolol. She reports that he has no bleeding
disorders. His labs are repeated and now his platelets are 101K,
INR 1.2.
6. Would this information alter your previous analgesic plan
and why?
Dr. Jacob: Our institution does not have any formal policies or
guidelines regarding placement of blocks in trauma patients.
Cases are handled individually at the discretion of the attending
anesthesiologist and in collaboration with surgery service.
Dr. Guha: Given that the repeat platelet count and INR indicate that
the patient is less coagulopathic, I would proceed with an epidural
catheter.
Dr. Blake: At my institution, we try to follow the ASRA
anticoagulation guidelines regarding medication history and
coagulation parameters. In general, we want the spines to be
cleared and the patient able to sit up for placement. There should
not be fractures/issues in the immediate area of placement. If
Dr. Gilloon: Yes, having a complete medication list that excluded
blood thinners other than aspirin along with repeat labs showing
platelets of 101 and an INR of 1.2 would make me comfortable
performing an epidural. A properly placed epidural will provide
better analgesia than a ketamine infusion. In my opinion, the
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American Society of Regional Anesthesia and Pain Medicine
2017
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