Uncomplicated removal of epidural catheters in 4365 patients with international normalized ratio greater than 1.4 during initiation of warfarin therapy

Spencer S. Liu, Asokumar Buvanendran, Eugene R. Viscusi, Erin Hutton, Timothy Lubenow, Jon Y Zhou, Pamela M. Shaw, Mario Moric, Suzanne Lenart

Research output: Contribution to journalArticle

24 Citations (Scopus)

Abstract

Background and Objectives: Current guidelines from the American Society of Regional Anesthesia state that an international normalized ratio (INR) of 1.4 is the upper limit of warfarin anticoagulation for safe removal of an epidural catheter. However, these guidelines are based primarily on expert consensus, and there is controversy regarding this recommendation as being "too conservative." Methods: Prospective (3211) and retrospective (1154) patients undergoing total joint replacement followed by daily warfarin thromboprophylaxis were enrolled in this observational study. All nonsteroidal anti-inflammatory drugs and anticoagulants were held before surgery, and all patients had normal coagulation test results before surgery. Patients were followed twice a day by the acute pain service, no other anticoagulants except nonsteroidal anti-inflammatory drugs were administered, and epidural analgesia was discontinued per institutional protocol. Only patients with INR greater than 1.4 at the time of removal of epidural catheter were included. Neurologic checks were performed for 24 hrs after removal. Results: A total of 4365 patients were included, and 79% underwent knee replacement and 18% hip replacement. Mean age was 68 yrs, and mean weight was 81 kg. Mean (SD) duration of epidural analgesia was 2.1 (0.6) days. Mean (SD) INR at the time of epidural removal was 1.9 (0.4), ranging from 1.5 to 7.1. No spinal hematomas were observed (0% incidence with 95% confidence interval, 0%-0.069%). Conclusions: Our series of 4365 patients had uncomplicated removal of epidural catheters despite INRs ranging from 1.5 to 5.9. Removal was only during initiation of warfarin therapy (up to approximately 50 hrs after warfarin intake) when several vitamin K factors are likely to still be adequate for hemostasis.

Original languageEnglish (US)
Pages (from-to)231-235
Number of pages5
JournalRegional Anesthesia and Pain Medicine
Volume36
Issue number3
DOIs
StatePublished - May 2011
Externally publishedYes

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International Normalized Ratio
Warfarin
Catheters
Epidural Analgesia
Anticoagulants
Replacement Arthroplasties
Anti-Inflammatory Agents
Therapeutics
Guidelines
Pain Clinics
Conduction Anesthesia
Vitamin K
Hemostasis
Hematoma
Nervous System
Observational Studies
Hip
Knee
Confidence Intervals
Weights and Measures

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Uncomplicated removal of epidural catheters in 4365 patients with international normalized ratio greater than 1.4 during initiation of warfarin therapy. / Liu, Spencer S.; Buvanendran, Asokumar; Viscusi, Eugene R.; Hutton, Erin; Lubenow, Timothy; Zhou, Jon Y; Shaw, Pamela M.; Moric, Mario; Lenart, Suzanne.

In: Regional Anesthesia and Pain Medicine, Vol. 36, No. 3, 05.2011, p. 231-235.

Research output: Contribution to journalArticle

Liu, Spencer S. ; Buvanendran, Asokumar ; Viscusi, Eugene R. ; Hutton, Erin ; Lubenow, Timothy ; Zhou, Jon Y ; Shaw, Pamela M. ; Moric, Mario ; Lenart, Suzanne. / Uncomplicated removal of epidural catheters in 4365 patients with international normalized ratio greater than 1.4 during initiation of warfarin therapy. In: Regional Anesthesia and Pain Medicine. 2011 ; Vol. 36, No. 3. pp. 231-235.
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abstract = "Background and Objectives: Current guidelines from the American Society of Regional Anesthesia state that an international normalized ratio (INR) of 1.4 is the upper limit of warfarin anticoagulation for safe removal of an epidural catheter. However, these guidelines are based primarily on expert consensus, and there is controversy regarding this recommendation as being {"}too conservative.{"} Methods: Prospective (3211) and retrospective (1154) patients undergoing total joint replacement followed by daily warfarin thromboprophylaxis were enrolled in this observational study. All nonsteroidal anti-inflammatory drugs and anticoagulants were held before surgery, and all patients had normal coagulation test results before surgery. Patients were followed twice a day by the acute pain service, no other anticoagulants except nonsteroidal anti-inflammatory drugs were administered, and epidural analgesia was discontinued per institutional protocol. Only patients with INR greater than 1.4 at the time of removal of epidural catheter were included. Neurologic checks were performed for 24 hrs after removal. Results: A total of 4365 patients were included, and 79{\%} underwent knee replacement and 18{\%} hip replacement. Mean age was 68 yrs, and mean weight was 81 kg. Mean (SD) duration of epidural analgesia was 2.1 (0.6) days. Mean (SD) INR at the time of epidural removal was 1.9 (0.4), ranging from 1.5 to 7.1. No spinal hematomas were observed (0{\%} incidence with 95{\%} confidence interval, 0{\%}-0.069{\%}). Conclusions: Our series of 4365 patients had uncomplicated removal of epidural catheters despite INRs ranging from 1.5 to 5.9. Removal was only during initiation of warfarin therapy (up to approximately 50 hrs after warfarin intake) when several vitamin K factors are likely to still be adequate for hemostasis.",
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AU - Hutton, Erin

AU - Lubenow, Timothy

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