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Enoxaparin bridging for neuraxial procedures: Is the 24 hour wait really enough?

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James Turner, MD, of Wake Forest Baptist Hospital discusses his Abstract #3379 which he will present at the 42nd Annual Regional Anesthesiology and Acute Pain Medicine Meeting on April 7, 2017.

Hello my name is jimmy turner i’m a regional anesthesia and acute pain medicine fellow here at wake forest baptist i’m going to talking about an abstract i’ll be submitting at the national meeting in azra regarding neuraxial procedures following an ox pairing treatment administration and whether the 24-hour recommended weight is truly long enough as for some

Background and knocks apparent at a 10 a inhibitor that is used for venous thromboembolism prophylaxis and treatment it is also used in the perioperative setting as a bridge for patients that are in chronic anticoagulation there are some recommendations that it’s not necessary to monitor an ox apparent use which is why it’s one of the favorites to be used in the

Perioperative setting however an occupation and the package insert does state that there are certain situations where caution or consideration should be given which includes patients who are elderly are low in weight or obese and patients that have severe renal impairment which they define as a creatinine clearance of less than 30 an oxy perrin was released in 1993

And the 88 years prior to its release there were 61 epidural hematomas that were reported in the literature in the subsequent five years after an ox parents release we almost doubled that number at 60 and so the ezra guidelines came out first in 1998 as consensus statements for what we should do in anticoagulation patients receiving anticoagulation and in this

Case they recommended a 24-hour wait after the last treatment dose of an oxy baron and suggested that treatment dose and ox parent did not need to be monitored it should be noted that as our made recommendations that patients comorbidities and other anticoagulants that the patient may be on should be considered when placing a patient on an ox and pairing however

When it comes to monitoring it must be mentioned also that there are very specific requirements it must be performed on a chromogenic assay here at wake forest we use a bio fan chromogenic a say on a siemens system and that that ass they must be titrated to particular drugs and so in this case we use a hybrid curve for an ox apparent and heparin and these must

Be explicitly stated to the laboratory that this is the drug coming down that we need to be testing for the literature does vary a little bit in terms of what a level should be for prophylactic and treatment dose range or therapeutic range for nox appearing but most would agree that a range of point2 international units 2.5 international units per ml would be a

Prophylactic range and that point five to one international units per ml would be a treatment or therapeutic range now these labs are normally taken at four hours or the peak dose after knox appearance administered it should be noted that other specialties have looked at an tight end a monitoring including the trauma literature and the orthopedic literature in

Addition to the american college of chest physicians recommending monitoring for patients that are pregnant or pediatric suggesting that anti 10 a level monitoring might be useful in these populations as well therefore we set out to have a quality improvement study because we’d noticed that patients anti 10-8 levels were elevated in certain patients we studied

25 patients and ended up analyzing 19 of them because six others were on other anticoagulants that would affect the anti 10 a level and then we looked at what their level was after meeting the 24-hour azra guideline so as you can see in the first graph where we show an tight end a levels versus time there’s a significant proportion of people that were above a

Prophylactic or therapeutic range despite having method 24-hour guideline in fact fifty-eight percent of patients in the study were found to be in that situation in the next graph you can see that age was also a significant factor as patients less than seven years old only one patient was above the prophylactic range for an anti 1080 level while only two patients

Over the age of 70 weren’t in other words over eighty percent of patients over the age of 70 were above a prophylactic or therapeutic range given their age and in the final graph you can see an anti tenant level as charted against the creatinine clearance which demonstrates the impact that creatinine clearance or renal function has on anti 1080 levels and as

Creatinine clearance decreases an anti ten a level is seen to be prolonged or the effect of an ox appearance seemed to prolonged for this reason we found that patients who have ground clearance even in the mild or moderate renal insufficiency stage may be at risk not just those in severe renal impairment so the take-home is that approximately sixty percent

Of fifty-eight percent of patients that we studied showed an anti ten a level in the prophylactic er therapeutic range in that patients over the age of 70 had eighty percent chance of having a anti tener level in the same range suggesting that anti 1080 level monitoring as found in other specialties might be useful in following an ox apparent and the doses we

Might be administering and when it might be safe to perform on our actual anesthetic this begs the question should we be using anti 10-8 levels in the same way that we use inrs for patients on warfarin or coumadin in order to make risk-benefit analysis to determine if it’s safe to proceed with under actual anaesthetic for this reason we suggest that further investigations necessary

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Enoxaparin bridging for neuraxial procedures: Is the 24 hour wait really enough? By ASRA – We’ve moved to a new site