American Society of Regional Anesthesia and Pain Medicine August 2017 - 22

lidocaine with epinephrine. If the trauma epidural patient is stable
after the initial test dose, from a cardiovascular standpoint, I will
often administer the other 2 mL of test dose that comes in the
epidural kit.
Dr. Rustameyer: I would place this epidural at T6-7. I'd start the
infusion at 4 mL/hr and increase it 1 mL/hr until adequate coverage
was achieved. The side effects I'd expect would be bradycardia and
hypotension if the epidural solution affected the cardiac accelerator
fibers. This is why I'd start with a low infusion and increase it
slowly.
You decide to place a T6/7 epidural. The patient feels his pain is
much better controlled just 2 hours after placement, and he has
weaned off BiPAP to nasal cannula 4L. The team provides deep
vein thrombosis (DVT) prophylaxis in the form of once daily low
molecular weight heparin (LMWH). His aspirin is stopped, and he
continues his other home pain medications.
Three days later, the patient is doing well on oral meds and after
the epidural has been shut off for 3 hours. He had his LMWH held
this morning but, unfortunately, a medication error occurred on your
patient and he received one 75 mg dose of clopidogrel yesterday
morning. The team is hoping you can remove the epidural so they
can send him home tomorrow.
8. How will you proceed with epidural management/possible
discontinuation for this patient?
Dr. Guha: ASRA does not make any specific requirements
regarding time interval to wait from last dose of clopidogrel until
removal of epidural catheter. I would first ensure that the previous
coagulopathy and thrombocytopenia had been corrected and that
the patient was not on any other anticoagulant or antiplatelet
agents. I would then wait five half-lives from the time of the last
clopidogrel dose and then remove the epidural catheter. LMWH
administered once daily for DVT prophylaxis must be held for 12
hours prior to catheter removal and not restarted until 4 hours later,
as per ASRA guidelines. I would monitor the patient for another
24 hours in the hospital after catheter removal with frequent
neurological assessments to ensure he is not developing signs of
an epidural hematoma.

22

Dr. Gilloon: The drug error is unfortunate and complicates the
epidural management. The ASRA guidelines recommend holding
clopidogrel for 7 days prior to epidural placement and withholding
clopidogrel while the catheter is in place. However, they do not
give guidance regarding a single dose of clopidogrel that is
administered in a patient with an epidural catheter. I typically apply
the same guidelines for epidural placement to epidural removal.
In my opinion, it is not practical to leave the epidural in place for
7 additional days due to this single dose of clopidogrel. I would
discuss the medication error with the patient and recommend
withholding additional doses of LMWH. I would wait 5 half-lives of
clopidogrel (30 hours) and remove the catheter. I would educate the
patient and family on signs of epidural hematoma, including back
pain, numbness, and paralysis. If the patient understood and could
self-monitor or had reliable caregivers, I would have the patient
discharged a few hours after the catheter was removed.
Dr. Jacob: I would remove the catheter, order every-4-hour neuro
checks for 24 hours to assess lower extremity motor and sensory
function, and request LMWH be held until the next morning.
Dr. Blake: After a single 75-mg oral dose, the half-life of
clopidogrel is approximately 6 hours. It takes 3 to 7 days of
clopidogrel dosing to reach a steady state of platelet inhibition.
I would make sure that the team does not give any further
clopidogrel or LMWH. I would have a discussion with the team,
patient, and patient's family about the risks of bleeding and
hematoma formation with removing the epidural. It is not very
practical to keep the patient in the hospital for 7 days from his
single dose of clopidogrel, for which the half-life is 6 hours. After
a thorough discussion of risks and benefits, I would likely remove
the epidural the following morning (2 days after his clopidogrel
dose and 24 hours after his last dose of LMWH). I would strongly
consider keeping him in the hospital that day and possibly one
more night for neurologic monitoring. When the patient does
discharge home, I would make sure myself or someone on my team
follows up with him at home via phone.
Dr. Rustameyer: If possible, I would assess platelet function. Giving
a platelet transfusion would be something else I'd consider. If I was
not able to assess platelet function, I wouldn't be willing to pull the
epidural catheter for approximately 48 to 72 hours.

American Society of Regional Anesthesia and Pain Medicine
2017



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

No label
American Society of Regional Anesthesia and Pain Medicine August 2017 - No label
American Society of Regional Anesthesia and Pain Medicine August 2017 - 2
American Society of Regional Anesthesia and Pain Medicine August 2017 - 3
American Society of Regional Anesthesia and Pain Medicine August 2017 - 4
American Society of Regional Anesthesia and Pain Medicine August 2017 - 5
American Society of Regional Anesthesia and Pain Medicine August 2017 - 6
American Society of Regional Anesthesia and Pain Medicine August 2017 - 7
American Society of Regional Anesthesia and Pain Medicine August 2017 - 8
American Society of Regional Anesthesia and Pain Medicine August 2017 - 9
American Society of Regional Anesthesia and Pain Medicine August 2017 - 10
American Society of Regional Anesthesia and Pain Medicine August 2017 - 11
American Society of Regional Anesthesia and Pain Medicine August 2017 - 12
American Society of Regional Anesthesia and Pain Medicine August 2017 - 13
American Society of Regional Anesthesia and Pain Medicine August 2017 - 14
American Society of Regional Anesthesia and Pain Medicine August 2017 - 15
American Society of Regional Anesthesia and Pain Medicine August 2017 - 16
American Society of Regional Anesthesia and Pain Medicine August 2017 - 17
American Society of Regional Anesthesia and Pain Medicine August 2017 - 18
American Society of Regional Anesthesia and Pain Medicine August 2017 - 19
American Society of Regional Anesthesia and Pain Medicine August 2017 - 20
American Society of Regional Anesthesia and Pain Medicine August 2017 - 21
American Society of Regional Anesthesia and Pain Medicine August 2017 - 22
American Society of Regional Anesthesia and Pain Medicine August 2017 - 23
American Society of Regional Anesthesia and Pain Medicine August 2017 - 24
American Society of Regional Anesthesia and Pain Medicine August 2017 - 25
American Society of Regional Anesthesia and Pain Medicine August 2017 - 26
American Society of Regional Anesthesia and Pain Medicine August 2017 - 27
American Society of Regional Anesthesia and Pain Medicine August 2017 - 28
American Society of Regional Anesthesia and Pain Medicine August 2017 - 29
American Society of Regional Anesthesia and Pain Medicine August 2017 - 30
American Society of Regional Anesthesia and Pain Medicine August 2017 - 31
American Society of Regional Anesthesia and Pain Medicine August 2017 - 32
American Society of Regional Anesthesia and Pain Medicine August 2017 - 33
American Society of Regional Anesthesia and Pain Medicine August 2017 - 34
American Society of Regional Anesthesia and Pain Medicine August 2017 - 35
American Society of Regional Anesthesia and Pain Medicine August 2017 - 36
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
http://www.brightcopy.net/allen/asra/16-3
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
https://www.nxtbookmedia.com