The safety of co-administered continuous epidural analgesia and low-molecular-weight heparin after major orthopedic surgery: Assessment of a standardized patient management protocol

2006 ◽  
Vol 96 (09) ◽  
pp. 387-389 ◽  
Author(s):  
Jenny Wang ◽  
Karl Cuddy ◽  
Meghan Wagler ◽  
Krystyna Kinnon ◽  
Mark Crowther ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Epidural Analgesia ◽  
Orthopedic Surgery ◽  
Low Molecular Weight Heparin ◽  
Patient Management ◽  
Standardized Patient ◽  
Low Molecular Weight ◽  
Management Protocol ◽  
Continuous Epidural Analgesia ◽  
Major Orthopedic Surgery

The Safety of Co-Administered Low-Molecular-Weight Heparin and Continuous Epidural Analgesia after Major Orthopedic Surgery: Assessment of a Standardized Management Protocol.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 704-704 ◽  
Author(s):  
Jenny Wang ◽  
James Douketis ◽  
Meghan Wagler ◽  
Krys Kinnon ◽  
Mark Crowther
Keyword(s):  
Epidural Analgesia ◽  
Epidural Catheter ◽  
Orthopedic Surgery ◽  
Epidural Hematoma ◽  
Low Molecular Weight ◽  
Management Protocol ◽  
Increased Risk ◽  
Continuous Epidural Analgesia ◽  
Major Orthopedic Surgery ◽  
The Mean

Abstract Background: In patients who have had major orthopedic surgery, low-molecular-weight heparin (LMWH) has established efficacy in preventing venous thromboembolism (VTE) after surgery, and continuous epidural analgesia (CEA) provides better pain control than parenteral analgesia and may reduce the risk of cardiorespiratory complications. However, there is concern about the co-administration of LMWH and CEA after surgery because of an increased risk of epidural hematoma. No study, to our knowledge, has investigated the safety of a standardized treatment regimen that allows co-administered LMWH and CEA after surgery. Patients and Methods: We assessed the safety of a standardized management protocol in 970 patients who were scheduled to undergo knee or hip replacement surgery and who received post-operative thromboprophylaxis with LMWH and pain control with CEA. All patients received intra-operative spinal (regional) anesthesia, with an indwelling epidural catheter left in place after surgery to administer epidural analgesia with an infusion of fentanyl and bupivacaine. Subcutaneous LMWH (enoxaparin 30 mg twice-daily or dalteparin 5000 IU daily) was started on the morning after surgery and continued for at least 5 days. CEA was administered for 2–3 days after surgery, with the epidural catheter removal occurring during the trough anticoagulant effect of the LMWH, 10 hours and 22 hours after the preceding dose of enoxaparin and dalteparin, respectively. In patients who were to receive warfarin, this treatment was initiated, with a 2.5 mg dose, on the evening prior to the scheduled removal of the epidural catheter. Drugs that are known to affect hemostasis were avoided during CEA, and patients at increased risk for bleeding were not given LMWH. During the period of hospitalization, we calculated the incidence and associated 95% confidence interval (CI) for the following outcomes: epidural hematoma; other bleeding (major and minor); VTE, myocardial infarction, stroke, death. Results: 970 patients (mean age: 68.2 years; mean weight: 81.4 kg; 63% female) who underwent knee replacement (527 patients) or hip replacement (443 patients) received co-administered LMWH and CEA. The mean duration of LWMH therapy was 7.2±5.3 days. The mean duration (±standard deviation) of CEA was 1.9±0.80 days, respectively. Warfarin was initiated in 758 (78%) patients. There were no episodes of symptomatic epidural hematoma (0%; 95% CI: 0–0.38). During the in-hospital follow-up period, there were 13 episodes of VTE (1.3%; 95% CI: 0.71–2.3), 47 bleeds (4.7%; 95% CI: 3.5–6.3); 4 myocardial infarcts (0.41%; 95% CI: 0.12–1.1), and 4 deaths (0.41%; 95% CI: 0.12–1.1). Conclusion: Co-administered LMWH and CEA appears safe after major orthopedic surgery when using a standardized management protocol.

Anticoagulant Effect at the Time of Epidural Catheter Removal in Patients Receiving Twice-daily or Once-daily Low-molecular-weight Heparin and Continuous Epidural Analgesia after Orthopedic Surgery

2002 ◽  
Vol 88 (07) ◽  
pp. 37-40 ◽  
Author(s):  
Krystyna Kinnon ◽  
Mark Crowther ◽  
James Douketis
Keyword(s):  
Molecular Weight ◽  
Epidural Analgesia ◽  
Epidural Catheter ◽  
Orthopedic Surgery ◽  
Low Molecular Weight Heparin ◽  
Anticoagulant Effect ◽  
Catheter Removal ◽  
Low Molecular Weight ◽  
Once Daily ◽  
Continuous Epidural Analgesia

SummaryIn patients who receive co-administered low-molecular-weight heparin (LMWH) and continuous epidural analgesia (CEA) after orthopedic surgery, there is concern about an increased risk of a spinal epidural hematoma. The practice of twice-daily LMWH dosing in North America might, in part, account for the greater number of epidural hematomas reports compared to Europe where once-daily LMWH is used. We performed a prospective cohort study in patients who had orthopedic surgery and received co-administered LMWH and CEA. We investigated the trough anticoagulant effect, as measured by an anti-Xa heparin level, at the time of epidural catheter removal in patients who received twice-daily or once-daily LMWH. Twenty-five patients who received enoxaparin, 30 mg twice-daily, and 25 patients who received dalteparin, 5,000 IU once-daily, had anti-Xa heparin levels measured on the second or third post-operative day at the time of epidural catheter removal. In patients who received twice-daily enoxaparin, or once-daily dalteparin, the anti-Xa heparin level was measured, on average, 10.4 h and 21.8 h, respectively, after the preceding LWMH dose. All 25 patients who received once-daily LMWH had an anti-Xa heparin level <0.10 U/ml at the time of catheter removal. Of 25 patients who received twice-daily LMWH, the anti-Xa heparin level at the time of catheter removal was >0.20 U/ml in 5 patients (P = 0.050), and >0.10 U/ml in 7 patients (P = 0.009). We conclude that in patients who are receiving co-administered LMWH and CEA after orthopedic surgery, twice-daily but not once-daily LMWH administration is more likely to be associated with a clinically important anticoagulant effect at the time of epidural catheter removal.

State-of-the-Art Review : Prevention of Venous Thromboembolism in Major Orthopedic Surgery

1996 ◽  
Vol 2 (3) ◽  
pp. 153-157
Author(s):  
Paolo Prandoni ◽  
Samuel Z. Goldhaber ◽  
Andrea Piccioli ◽  
Antonio Girolami
Keyword(s):  
Molecular Weight ◽  
Venous Thromboembolism ◽  
Orthopedic Surgery ◽  
Hip Replacement ◽  
Low Molecular Weight Heparin ◽  
State Of The Art ◽  
Intermittent Pneumatic Compression ◽  
Low Molecular Weight ◽  
Efficacy And Safety ◽  
Major Orthopedic Surgery

Venous thromboembolism continues to be a major source of morbidity and mortality in both elective and traumatic orthopedic surgery. Prevention of this complication has received much attention in the orthope dic literature in recent years. We reviewed the relative efficacy and safety of various agents in the prophylaxis of venous thromboembolism arising after major orthopedic surgery. In patients undergoing total hip replacement, low-molecular-weight heparin in fixed doses, adjusted doses of warfarin, and unfractionated heparin in adjusted doses are the most effective prophylactic agents and are highly recommended for routine use. Low-molecular- weight heparin or warfarin should be used in patients with hip fractures. Low-molecular-weight heparin, warfarin, or intermittent pneumatic compression should be used in patients undergoing major knee surgery. A number of questions still remain unanswered. In particular, further studies are needed to establish the optimal duration of prophylaxis.

Can We Do Better? Identifying Orthopedic Surgery Patients at High Risk for Venous Thromboembolism Despite Thromboprophylaxis.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1782-1782
Author(s):  
Susan R. Kahn ◽  
Renee L. Schiff ◽  
Ian Shrier ◽  
Wahbi Hammouda ◽  
David Zukor
Keyword(s):  
Risk Factors ◽  
Molecular Weight ◽  
Venous Thromboembolism ◽  
Confidence Interval ◽  
Orthopedic Surgery ◽  
Low Molecular Weight Heparin ◽  
Patient Characteristics ◽  
Low Molecular Weight ◽  
Care Hospital ◽  
Major Orthopedic Surgery

Abstract Background Routine administration of thromboprophylaxis is the standard of care for patients undergoing major orthopedic surgery due to the very high rate of postoperative venous thromboembolism (VTE). However, because prophylaxis is not 100% effective, a significant proportion of patients who receive thromboprophylaxis develop post-operative VTE (“breakthrough VTE”). Clinical and surgical characteristics that are associated with the development of VTE in orthopedic surgery patients who receive standard thromboprophylaxis have not been well characterized. Objectives To evaluate the incidence of and risk factors for breakthrough VTE in patients who underwent major orthopedic surgery at a tertiary care hospital in Montreal, Canada. Methods Charts from consecutive patients who underwent total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS) (hip pinning or hemiarthroplasty) from August 1, 1999 to April 30, 2000 were abstracted using standardized case report forms. Data were collected on patient characteristics (including VTE risk factors and postoperative complications), surgical characteristics (including type of surgery, operative factors, type of anesthetic) and thromboprophylaxis regimen. The results of any tests performed for clinically suspected VTE were documented, and associations between potential risk factors and objectively confirmed VTE were examined. Results Over the 9 month study period, 310 patients underwent major orthopedic surgery (34% THA, 30% TKA, and 36% HFS) and received standard thromboprophylaxis with either dalteparin or enoxaparin (mean duration of prophylaxis: 7 days). Of 83 suspected VTE, 44 (7 proximal DVTs and 37 distal DVTs; 14% of study population; median onset 6 days post-op) were confirmed with objective testing (compression ultrasonography). Multivariate analyses showed that knee surgery (odds ratio [OR] 4.8, 95% confidence interval 2.3, 10.1) and type of low molecular weight heparin (enoxaparin: protective) (OR 0.39, 95% confidence interval 0.20, 0.80) independently predicted VTE. Patient characteristics such as previous VTE, malignancy, hormonal therapy or varicose veins were not associated with VTE. Conclusion Despite receiving standard thromboprophylaxis, 14% of patients undergoing major orthopedic surgery developed symptomatic breakthrough VTE. Factors that independently predicted VTE in our population were TKR surgery and type of low molecular weight heparin. Our results suggest that TKR patients may warrant more aggressive post-operative physiotherapy and ambulation and adjunctive prophylactic measures such as pneumatic compression. In addition, due to the heterogeneity of different low molecular weight heparin compounds, direct comparison of the effectiveness of enoxaparin with dalteparin for orthopedic prophylaxis in prospective, randomized trials seems warranted.

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