Findings Support Less Cautious Stance On Catheter Removal

by Michael Vlessides
Las Vegas—A multicenter study of more than 4,000 patients has confirmed what many clinicians have suspected and several smaller studies have suggested: Epidural catheters can be removed safely despite INRs higher than 1.4 during the initiation of warfarin therapy.
The investigators—including researchers from Rush University Medical Center and Thomas Jefferson University—sought to tackle the controversy that the ASRA guidelines may be too conservative.

A total of 4,365 patients—3,211 prospective and 1,154 retrospective—were enrolled in the observational study. All patients underwent total joint replacement followed by daily warfarin thromboprophylaxis. All patients had normal coagulation test results prior to surgery; nonsteroidal anti-inflammatory drugs (NSAIDs) and anticoagulants were withheld prior to surgery.The mean age of the participants was 68 years, and their mean weight was 81 kg. Most (79%) underwent total knee replacement surgery. The mean duration of epidural analgesia was 2.1±0.6 days.

Epidural analgesia was discontinued following institutional protocol. Only patients with an INR greater than 1.4 when their epidural catheter was removed were included in the study. Participants were followed twice a day by the acute pain service, and neurologic checks were performed every two hours for 24 hours after removal. No other anticoagulants except NSAIDs were administered.

Ms. Shaw reported at the 2011 ASRA annual meeting (abstract 54) that although the mean INR at time of epidural removal was 1.9±0.4, no spinal hematomas were observed. Yet Ms. Shaw, whose poster was named one of the best at the meeting, noted that catheters were removed when warfarin therapy was initiated—a time when several vitamin K factors are likely to be adequate for hemostasis.The findings, she added, do not necessarily contradict current ASRA guidelines, as the researchers followed recommendations to cautiously remove catheters and perform subsequent neurologic checks.

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